https://www.pexels.com/photo/boy-child-clouds-kid-346796/

Childhood Abdominal Migraines

I recently got an opportunity to talk with a representative from the Diamond Headache Clinic and they have shared this awesome presentation on childhood migraines, including abdominal migraines that were actually one of the first diagnoses I considered when I first began looking for answers to explain some of the many gastrointestinal symptoms I had as a young child myself. I thought this presentation could be a really good resource to share here in case any of these symptoms can help anyone still looking for answers for their own symptoms.

Courtesy of https://www.diamondheadache.com/

Sinus Surgery and Recovery 

I wish someone would have told me of all the horrors I’d find in the aftermath of my sinus surgery. I really feel like I wasn’t prepared for this at all and I did my due diligence in researching this procedure before even committing to it – or so I thought:

  • I read everything I could find  online
  • I talked about it in-depth with my surgeon
  • I even talked to friends and family who have had sinus surgery themselves (and not that long ago I might add)

But nothing – NOTHING – could have prepared me for the reality of this surgery. It’s like they knew nobody in their right mind would go through with it if they had told the truth. So, in the spirit of patient education and the level of honesty I put forward on this blog [even if it is highly embarrassing at times],  I figured I’d provide the truth – the REAL truth.

I am  giving you fair warning now – the following will not be pleasant

and I have the pictures to prove it!

If you’re really squeamish or easily grossed out, please do yourself  a favor and skip over this post.

If you do decide to proceed, however, you do so at your own risk.

Please don’t say I didn’t warn you.


Background:

As I had mentioned in a previous update, my new neurologist had finally ordered an MRI of the Head/Brain after years and years of me begging every other doctor I saw to have one done. Really, I just wanted to see if my symptom were really inside of my head this whole time like everyone kept telling me it was.

In case you were wondering, here’s what my brain actually looks like:

mri-of-the-head-and-brain-1mri-of-the-head-and-brain-2

Here’s what the MRI report said:

mri-report-1

Well, at least my brain is functioning appropriately. 

My sinuses, however, not so much…

The neurologist decided to refer me to an ENT to see what needed to be done. After the reading the reports and looking over my long case history, the ENT didn’t originally believe that my sinuses were that bad. However, he did say that the sinus cavity is better viewed using a CT rather than MRI, so he ordered a CT scan without contrast to rule out the possibility that I might need surgery to fix my sinuses.

managing-fall-allergies-and-asthma-23-728

This is a copy of my CT report:

ct-sinus-report

I guess I was going to need surgery after all.

Bummer.

icd-code


Surgery Prep:

The night before surgery, my occipital and posterior auricular lymph nodes suddenly began to swell and were extremely painful. I started to become really worried I wouldn’t be able to do the surgery, so I called the doctor on-call and he didn’t seem too concerned about it. He just told me to wait and see how I felt in the morning.

Luckily, the only surgical prep I had to do the night before was to stop food and water 8 hours before. However, I was allowed to take all my medications on the morning of the procedure and was allowed a few sips of water to get them down.

I still felt super sick that morning, although I decided to go through with the surgery anyway. Fortunately, my lymph node swelling had gone done for the most part. My stomach pain and nausea were so bad, though, that I had to take meds just to get myself into the car for the 15-minute drive to the hospital. Really, the last thing I wanted to do that morning was to have surgery but I also didn’t want to have to prep again either. However, while laying in the hospital bed waiting for the nurse to take me back for the procedure, I honestly began to regret this decision.

The Procedures:

Functional Endoscopic Sinus Surgery (FESS):

sinus_diagram

Given the extent of the opacification and the number of procedures I was having,  my surgery needed to be done endoscopically in the hospital, instead of outpatient in office as some of these procedures are.

Taken from the American Academy of Otolaryngology website (2015 ):

Developed in the 1950s, the nasal endoscope has revolutionized sinusitis surgery. In the past, the surgical strategy was to remove all sinus mucosa from the major sinuses. The use of an endoscope is linked to the theory that the best way to obtain normal healthy sinuses is to open the natural pathways to the sinuses. Once an improved drainage system is achieved, the diseased sinus mucosa has an opportunity to return to normal.

FESS involves the insertion of the endoscope, a very thin fiber-optic tube, into the nose for a direct visual examination of the openings into the sinuses. With state of the art micro-telescopes and instruments, abnormal and obstructive tissues are then removed. In the majority of cases, the surgical procedure is performed entirely through the nostrils, leaving no external scars. There is little swelling and only mild discomfort.

The advantage of the procedure is that the surgery is less extensive, there is often less removal of normal tissues, and can frequently be performed on an outpatient basis. After the operation, the patient will sometimes have nasal packing. Ten days after the procedure, nasal irrigation may be recommended to prevent crusting.

Septoplasty:

septoplasty

Taken from the American Academy of Otolaryngology website (2016 ):

The shape of your nasal cavity could be the cause of chronic sinusitis. The nasal septum is the wall dividing the nasal cavity into halves; it is composed of a central supporting skeleton covered on each side by mucous membrane. The front portion of this natural partition is a firm but bendable structure made mostly of cartilage and is covered by skin that has a substantial supply of blood vessels. The ideal nasal septum is exactly midline, separating the left and right sides of the nose into passageways of equal size.

Estimates are that 80 percent of all nasal septums are off-center, a condition that is generally not noticed. A “deviated septum” occurs when the septum is severely shifted away from the midline. The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose. The symptoms are usually worse on one side, and sometimes actually occur on the side opposite the bend. In some cases the crooked septum can interfere with the drainage of the sinuses, resulting in repeated sinus infections.

Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is not generally performed on minors, because the cartilaginous septum grows until around age 18. Septal deviations commonly occur due to nasal trauma.

A deviated septum may cause one or more of the following:

  • Blockage of one or both nostrils
  • Nasal congestion, sometimes one-sided
  • Frequent nosebleeds
  • Frequent sinus infections
  • At times, facial pain, headaches, postnasal drip
  • Noisy breathing during sleep (in infants and young children)

In some cases, a person with a mildly deviated septum has symptoms only when he or she also has a “cold” (an upper respiratory tract infection). In these individuals, the respiratory infection triggers nasal inflammation that temporarily amplifies any mild airflow problems related to the deviated septum. Once the “cold” resolves, and the nasal inflammation subsides, symptoms of a deviated septum often resolve, too.

Septoplasty is a surgical procedure performed entirely through the nostrils, accordingly, no bruising or external signs occur. The surgery might be combined with a rhinoplasty, in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery.

The time required for the operation averages about one to one and a half hours, depending on the deviation. It can be done with a local or a general anesthetic, and is usually done on an outpatient basis. After the surgery, nasal packing is inserted to prevent excessive postoperative bleeding. During the surgery, badly deviated portions of the septum may be removed entirely, or they may be readjusted and reinserted into the nose.

If a deviated nasal septum is the sole cause for your chronic sinusitis, relief from this severe disorder will be achieved.

SMR Turbinate Reduction:

inferior-turbinate-reduction

turbinate_reduction_2

Taken from the American Rhinologic Society website (2015):

There are many ways to shrink the size of the turbinates. Surgery is typically called turbinate reduction or turbinate resection. Surgery can be performed either in the office or in the operating room. In many instances, turbinate surgery and septoplasty are performed at the same time.
It is important that the turbinate not be removed completely because that can affect the function of the turbinates. Complete turbinate removal can result in a very dry and crusty nose. Occasionally, turbinate tissue will re-grow after turbinate surgery and the procedure may need to be repeated. This is preferable to the situation of totally removing the turbinate.

You may hear of many different terms being used when it comes to surgery for the turbinates. Examples of these terms are cauterization, coblation, radiofrequency reduction, microdebrider resection, and partial resection. These all refer to different methods of reducing the size of the turbinates.

Some of these methods shrink the turbinates without removing the turbinate bone or tissue. These methods include cauterization, coblation, and radiofrequency reduction. In each of these methods, a portion of the turbinate is heated up with a special device. Over time, scar tissue forms in the heated portion of turbinate, causing the turbinate to shrink in size.

With some of the other procedures, a portion of the turbinate is removed. It is important that enough of the turbinate be left intact so that the turbinate can warm and humidify the air that is flowing through the nose. A procedure called submucosal resection is a common technique used to treat enlarged turbinates. With this procedure, the lining of the turbinate is left intact, but the “stuffing” from the inside of the turbinate is removed. As the turbinate heals, it will be much smaller than before surgery. Sometimes, this resection can be performed with a device called a microdebrider. This device allows the surgeon to remove the “stuffing” through a small opening in the turbinate. In some instances, more of the turbinate is removed.

In some instances, packing may be placed in your nose during the healing process.

I was lucky enough to receive absorbable packing and sutures for my surgery – I heard the removal of the other kind of nasal packing and stenting is awful, though.

Maxillary Antrostomy w/ Removal of Maxillary Tissue:

Endoscopic anatomy of the pterygopalatine fossa

Endonasal endoscopic approach to the pterygopalatine fossa. (A) Maxillary antrostomy made in the medial wall of the maxillary sinus. A mucoperiosteal flap is reflected posteriorly to the crista ethmoidalis (CE) to expose the sphenopalatine artery (SPA) and posterior nasal artery (PNA) emerging from the sphenopalatine foramen. (B) Crista ethmoidalis and sphenopalatine foramen are enlarged with a drill. The posterior wall of the maxillary sinus is removed in a medial-to-lateral manner to the edge of the infraorbital nerve (IN). Elevation of the large fat pad, occupying the pterygopalatine fossa, exposes the internal maxillary artery (IMA) and its branches, the sphenopalatine and posterior nasal arteries, which are clipped and ligated. (C) With the use of a drill or Kerrison rongeur, the greater palatine nerve (GPN) is safely mobilized from its bony canal inferiorly. Gentle lateral retraction of the ganglion and GPN reveals the vidian nerve (VN) emerging from the vidian canal (VC) and exposes the pterygoid plate. (Reprinted with permission the Mayfield Clinic.)

Taken from the New York Head and Neck Institute website (2016):

Surgery begins with careful inspection of the nose. Key landmarks are the three turbinate bones or conchae (conchae = shell) arising from the lateral nasal wall and the ostiomeatal complex (a complex where the maxillary, ethmoid and frontal sinuses drain into the side wall of the nose). The most anterior, or nearest to the front structure within the ostiomeatal complex, is the uncinate process. This semilunar (half moon shaped) ridge of bone projects in front of the ostium of the maxillary sinus. Behind or posterior to the uncinate process, is a group of ethmoid cells known as the bulla ethmoidalis. The first step in ethmoidectomy is the careful and atraumatic removal of the uncinate process to visualize the ethmoid sinus and maxillary ostium. In our experience, incomplete removal of the uncinate process is a significant factor in leading to revision surgery. We believe that the uncinate should be removed at its attachment to the lateral nasal wall.

Endoscopic view of right nose showing uncinate process (up) and middle turbinate (mt). Ethmoidectomy begins with probing the space between the uncinate process and bulla ethmoidalis known as the ethmoid infundibulum (infundibulum = funnel-like). Endoscopic view of right nose showing uncinate process (up) and middle turbinate (mt). Ethmoidectomy begins with probing the space between the uncinate process and bulla ethmoidalis known as the ethmoid infundibulum (infundibulum = funnel-like).

 

Often complete removal of the uncinate process reveals the natural ostium or drainage pathway of the maxillary sinus into the nose. Various instruments have been designed to enlarge the maxillary ostium and remove the uncinate process. How much to enlarge the natural ostium of the maxillary sinus, also known as an antrostomy (antrostomy = to drain or make a permanent opening in the maxillary sinus to the nose), remains the subject of debate. Some surgeons prefer to only expose the natural ostium, while others routinely remove much of the maxillary sinus wall as part of this step of the procedure. All agree that the antrostomy must include the natural ostium of the sinus because mucocilliary flow is directed to the ostium and mucous may re-enter the sinus through the antrostomy. This so-called “circus effect”, which leads to reinfection of this sinus, is avoided by incorporating the natural ostium in the antrostomy.

Confining maxillary sinus surgery to primarily restoring the drainage pathway of the sinus into the nose is a significant departure from the pre-minimally invasive or functional sinus surgery era. Traditionally, theCaldwell Luc procedure was an integral part of maxillary and ethmoid sinus surgery. However, the American anatomist J. Parsons Schaefer recognized that the “maxillary sinuses are often the cesspool for infectious material from the frontal sinus (sinus frontalis) and certain anterior group of cellulae ethmoidalis” (ethmoid sinus air cells). That is, Schaeffer was implying that the maxillary sinusitis was often the result of infected drainage from the ethmoid and frontal sinuses, and not the cause of infection in these sinuses. In the modern era of sinus surgery, Caldwell Luc is reserved for disease processes such as fracturs or tumors which cannot be treated through an endoscopic transnasal approach.

Endoscopic image of the right nose showing completion of removal of the uncinate process by a debrider exposing the natural ostium of the maxillary sinus (mt = middle turbinate). Following the antrostomy, the maxillary sinus is inspected and polyps, fungus or infected secretion are removed. An uncommon complication of antrostomy is to injure the nasolacrimal duct (arrows) which drains tears into the nose. When such injuries do occur, the patient may have no problems because the tears drain directly into the nose at the site of injury. Less often the patient experience epiphoria or tears flowing onto the cheek. In such individuals, a dacryocystorhinotomy (DCR) reestablishes the normal drainage into the nose. Axial cadaver section through the ethmoid sinus. Enlargement outlines the infundibulum (infundibulum = funnel-like) drainage pathway of the ethmoid (yellow) which is bounded anteriorly by the uncinate process (yellow arrow) and posteriorly by the cells of the bulla ethmoidalis. After the uncinate process is removed, ethmoidectomy consist of exenteration of the ethmoid cells. From Schaefer SD et al. The combined anterior-to-posterior and posterior-to-anterior approach to ethmoidectomy: An update. Laryngoscope 116:509-513, 2006.
Endoscopic image of the right nose showing completion of removal of the uncinate process by a debrider exposing the natural ostium of the maxillary sinus (mt= middle turbinate). Following the antrostomy, the maxillary sinus is inspected and polyps, fungus or infected
secretion are removed.
An uncommon complication of antrostomy is to injure the nasolacrimal duct (arrows) which drains tears into the nose. When such injuries do occur, the patient may have no problems because the tears drain directly into the nose at the site of injury. Less often the patient experience epiphoria or tears flowing onto the cheek. In such individuals, a dacryocystorhinotomy (DCR) reestablishes the normal drainage into the nose. Axial cadaver section through the ethmoid sinus. Enlargement outlines the infundibulum (infundibulum = funnel-like) drainage pathway of the ethmoid (yellow) which is bounded anteriorly by the uncinate process (yellow arrow) and posteriorly by the cells of the bulla ethmoidalis. After the uncinate process is removed, ethmoidectomy consist of exenteration of the ethmoid cells. From Schaefer SD et al. The combined anterior-to-posterior and posterior-to-anterior approach to ethmoidectomy: An update. Laryngoscope116:509-513, 2006.

 My list of medications while in the hospital:

medications


Discharge Instructions:

GENERAL DISCHARGE INSTRUCTIONS:

For the next 24 hours or while taking narcotics:

  • Do NOT drive or operate any motorized equipment
  • Do NOT drink alcohol
  • Do NOT use marijuana products
  • Do NOT make any important decisions

CALL 911 OR REPORT TO THE ER IF YOU HAVE…Chest pain

  • Difficulty breathing
  • Sharp cramping calf pain
  • Sudden weakness to any part of your body
  • Sudden uncontrolled bleeding
  • Just don’t “feel” right or you’re suddenly nervous

CALL YOUR MD’S OFFICE FOR…

  • New, uncontrolled, or worsening pain
  • Unable to void after 8 hours
  • 101-degree temperature
  • Questions concerning any surgical dressings
  • Redness, swelling or foul-smelling drainage

ACTIVITY

The first 24 hours after your procedure, you must have a responsible adult available to assist you.

If you use oxygen at home continue to do so.

It can be normal to have dizziness, drowsiness, a sore throat, headache, or muscle aches. Call your MD if it becomes persistent.

Just take it easy for the rest of the day and gradually increase your activity level.

You may resume showering tomorrow unless your MD tells you otherwise.

DIET

Some nausea or vomiting is expected after anesthesia, call your MD if it becomes persistent.

Start with clear liquids (any liquid you can see through).

If no nausea, slowly return to eating your normal diet.

If you are nauseated, remain on clear liquids until it passes.

If your MD ordered a medicine to help with nausea, take this as directed.

If you have any questions or concerns, call your MD.

Sleep Apnea or Suspected Obstructive Sleep Apnea

You have received this handout because either you have sleep apnea or your health care provider suspects you may have Obstructive Sleep Apnea (OSA).

Obstructive sleep apnea (OSA) is also called sleep apnea. During normal sleep, muscles keep your throat open. This lets the air pass through easily. With OSA, the muscles and tissues around your throat relax and block or partially block air from passing through your windpipe. You may stop breathing for ten or more seconds, many times during your sleep. This causes your blood oxygen level to drop, which can strain the heart and blood vessels. This can also lead to high blood pressure, heart disease, and even death.

You may wake up during the night to catch your breath. You may feel tired and sleepy the next day. You may also have a hard time doing your usual activities.

It is important to know for sure if you have OSA. Follow up with your primary healthcare provider.

A sleep disorders center diagnoses sleep apnea. Treatments may include wearing a constant positive airway pressure mask (CPAP) while you sleep. Other options may also be considered. The results of the sleep study will guide the right treatment.

When you are at home and you have OSA or are suspected of having OSA:

  • Do not have alcohol or use sedative medicine before you sleep. These allow the muscles and tissues around your throat to relax and block the airflow to your lungs.
  • Sleep on your side or use pillows designed to prevent OSA. This keeps your tongue or other tissues from blocking your throat. You can also try raising the head of your bed or try sleeping on several pillows. Sewing a sock that holds a tennis ball to the back of your pajama top may stop you from sleeping on your back.
  • If you have OSA, follow your treatment plan. Special devices that you put in your mouth, called dental appliances, may help. If you have sleep apnea, you may have a CPAP machine to help you breathe while sleeping. Use this during your recovery unless specifically asked not to use by your surgeon.
  • Do not take sleep aids while taking pain medicine.
  •  If you have chest pain or trouble breathing, get help right away or call 911.

MEDICATIONS TO TAKE HOME:

medications-to-go-home

POST-OP INSTRUCTIONS:

Although the following set of  instructions were taken directly from the John Hopkins  (2016) website, they are quite similar to the directions I was provided by my own surgeon.

What to Expect After Endoscopic Sinus Surgery:

  • Bleeding:  It is normal to have some bloody discharge for the first 3-5 days after sinus surgery, especially after you irrigate your sinuses.  If steady bleeding occurs after surgery, tilt your head back slightly and breathe through your nose gently.  You may dab your nose with tissue but avoid any nose blowing.  If this does not stop the bleeding you may use Afrin spray.  Several sprays will usually stop any bleeding.  If Afrin fails to stop steady nasal bleeding then you should call our office or the on call doctor (see contact below).
  • Pain:  You should expect some nasal and sinus pressure and pain for the first several days after surgery.  This may feel like a sinus infection or a dull ache in your sinuses.  Extra-strength Tylenol is often all that is needed for mild post-operative discomfort. You should avoid aspirin and NSAIDs such as Motrin, Advil, and Aleve (see below). If Tylenol is not sufficient to control the pain, you should use the post-operative pain medication prescribed by your doctor. 
  • Fatigue:  You can expect to feel very tired for the first week after surgery.  This is normal and most patients plan on taking at least 1 week off of work to recover.  Every patient is different and some return to work sooner.
  • Nasal congestion and discharge:  You will have nasal congestion and discharge for the first few weeks after surgery.  Your nasal passage and breathing should return to normal 2-3 weeks after surgery.
  • Postoperative visits:  You will have a certain number of postoperative visits depending on what surgery you have.  During these visits we will clean your nose and sinuses of fluid and blood left behind after surgery.  These visits are very important to aid the healing process so it is essential that you attend all those scheduled for you.  There is some discomfort involved with the cleaning so it is best to take a pain medication (described above) 45 minutes before your visit.

What to Avoid After Endoscopic Sinus Surgery:

  • Nose Blowing and Straining:  You should avoid straining, heavy lifting (> 20 lbs) and nose blowing for at least 10 days after surgery.  Straining or nose blowing soon after surgery may cause bleeding.  You can resume 50% of your regular exercise regimen at 1 week after surgery and your normal routine 2 weeks after surgery.
  • Aspirin or Non-steroidal Anti-inflammatory (NSAIDs) medications:  Aspirin and NSAIDs such as Motrin, Advil, and Aleve should be stopped 2 weeks prior to surgery.  Aspirin and NSAIDs such may cause bleeding and should be avoided for 2 weeks after surgery.
  • Steroid Nasal Sprays:  If you were taking nasal steroid sprays prior to surgery you should avoid using these for at least 2 weeks after sinus surgery to allow the lining of the nose and sinuses to heal.  Your doctor will tell you when it is safe to restart this medicine.

Postoperative Care Instructions:

  • Nasal Saline Spray: Nasal saline mist spray can be used every 2-3 hours after surgery and can make your nose more comfortable after surgery.  These sprays (Ayr, Ocean, Simple Saline) are over-the-counter medications and can be purchased in any pharmacy
  • Sinus Irrigations:  You will start the sinus irrigations with the sinus rinse kits (NeilMed Sinus Rinse Kit) the day after surgery.  This must be performed at least twice daily.  Your doctor or nurse will show you how to perform the irrigations.  At first they will feel strange if you haven’t done them before.  Soon, however, they will become quite soothing as they clean out the debris left behind in your sinuses after surgery.  You can expect some bloody discharge with the irrigations for the first few days after surgery.  These irrigations are critical for success after sinus surgery!


Recovery Log:

Day 0:

Just got home from surgery a few hours ago. Sadly, I look better than I feel. Although you can’t really see it in this picture, I definitely vomited in my hair a little bit – good times. It can only go up from here my friends.

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And, in case you’re wondering, that thing under my nose is to catch all the blood coming out from my nose. Luckily I’m not bleeding that bad – at least yet. We’ll see how the day goes.

Day 4:

It’s true what they say about recovering from this surgery – it really does feel like you have the worst sinus infection ever. Like ever, ever. I feel like I’ve been hit in the face with a shovel and no, I’m not joking. My face is super swollen and painful today. However, I also fell behind on taking my painkillers because I slept nearly all day.

My face is super swollen and painful today. However, I also fell behind on taking my painkillers because I slept nearly all day. Remind me never to do that again.

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Day 7:

Had my first follow up with the surgeon today. He said that I’m healing well and that the pathology report on all the “gunk” he pulled out of my face came back as normal. However,  he also said he’s never had a patient with that much opacification have a normal report without something causing it. I’m just one of the lucky ones, I guess. Nothing odd about the way my body reacts really surprises me anymore. But I am just glad it wasn’t the result of any type of disease or a fungal infection.

Pathology Report

I still look and feel terrible, though. The doctor also did some debriding while I was at the office, so I can at least breathe a little better. My next follow-up is in three weeks from today.

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Day 10: 

Left a message for the ENT nurse to call me back regarding the odd smell in my nose. Do I need another appointment? Antibiotics? Please make this smell go away!

Really, the only way I can describe it is rotting flesh… or maybe meat… rotting something. There’s no way to hide from it – it’s in my nose. And every time I breathe in – I gag. God help me.

Day 11:

THIS just came out of my nose. It looks and feels like cartilage. I know it’s not but that doesn’t make it any better. At least it’s not the blood clots I was blowing out earlier in the week. Please don’t judge me by what comes out of my face.

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Day 12:

Went back to the surgeon to make sure I didn’t have an infection, despite the fact that I just saw him a few days ago and he said everything was fine. After what came out of my face yesterday,  I just wanted some reassurance. I’m happy to report that everything seems to be looking good.

The doctor did say that there were some debris and crusting in the right middle meatus, which he got out using the endoscopic suction and forceps. There was also a moderate amount of mucus, so he performed some more debridement as well.  Unfortunately, the grossness  I was seeing [and SMELLING] is a “normal” part of the healing process. Normal… yeah, okay.

Day 17

There are simply no words to accurately describe the true horror of watching this come out of your own face…. I’m honestly disgusted with myself.

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Day 21:

Today was my 3-week check up since surgery.

A friend of mine  drove me to the appointment and had the pleasure of watching the doctor pull some of the remaining scabs out and the look on her face was priceless. She said one of the scabs he pulled out was about a half of an inch to an inch long. Lovely, isn’t it? Hopefully, I haven’t scared her away.

Day 30:

I’m slowly starting to feel better thankfully. I still have occasional scabs coming out but they are few and far between. The scabs are also a lot less gross than they were before, although they do still smell of something terrible. I think the shape of my nose is finally looking more normal as well. Even though it has taken much longer to recover than expected, I am still hopeful that this surgery will be worth it in the long-run.

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Day 60:

I am two months post-op and, finally, I  think I am almost to the point of being completely healed. I can actually breathe better and I haven’t had anything else horrific come out of my face in a while. I’ve been keeping up with the sinus rinses every day, mostly because it seems to be helping my normal seasonal allergies as well. My oxygen saturation has also been at 99% and 10o% at my last few doctors appointments, which is a huge improvement. I really hope this means that the upcoming allergy and flu seasons will be much easier than the last few years in which I had a sinus infection almost every month or two. I guess only time will tell.

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References:

American Academy of Otolaryngology (2015). Sinus Surgery. Retrieved from http://www.entnet.org/?q=node/1429

American Academy of Otolaryngology (2016). Deviated Septum. Retrieved from http://www.entnet.org/content/deviated-septum

American Rhinologic Society (2015). Septoplasty & Turbinate Surgery. Retrieved from http://care.american-rhinologic.org/septoplasty_turbinates

John Hopkins Medicine (2016). Otolaryngology-Head and Neck Surgery. Retrieved from http://www.hopkinsmedicine.org/otolaryngology/specialty_areas/sinus_center/procedures/post_operative_instructions.html

 New York Head and Neck Institute (2016). Endoscopic Ethmoidectomy & Antrostomy: Operative Technique. Retrieved from http://www.nyhni.org/Centers-and-Services/Sinus-and-Allergy/What-are-the-surgical-treatments-of-sinusitis-and-/Endoscopic-Ethmoidectomy—Antrostomy–Operative-T

New Doctors, More Testing, and Surgery

Back in April, I finally got an appointment with the neurologist here in my town after waiting over a year for my new patient appointment. Although I had a neurologist up in Denver in the interim, he was simply just an okay doctor in my opinion – while he supported my theory of a POTS diagnosis (which I ultimately received last summer), he kept referring everything to my cardiologist and didn’t really seem that interested in doing his own investigation of my symptoms. He was also an hour’s drive away when there was little to no traffic, so I was obviously excited to finally have a specialist here in town. Immediately after meeting with the new doctor, I could see why there was such a long wait to get into the practice – she was fabulous!

After reviewing my case in detail, she was horrified that no one had done an MRI of my head as of yet – Thank you! That’s what I’ve been saying – especially considering the number of head injuries I’ve had back when I was cheerleading. She also ordered another Electroencephalogram (EEG) since evidently my first EEG was only reviewed by the technician who performed it and was never signed off by my neurologist, which was a lovely finding I might add. Thankfully, my EEG came back as being normal again, confirming that I was NOT having temporal lobe or partial seizures as both neurologists had suspected based on my primary neurological symptoms of migraines, cognitive impairment, visual aura, and olfactory hallucinations. Basically, the negative EEG results confirmed that I was suffering from Status Migrainous or intractable chronic migraines as originally suspected. Although I had started taking gabapentin after my first appointment with the neurologist, which seemed to provide a little bit of relief of my symptoms, the doctor decided to also start Botox Injections since the migraines were confirmed to hopefully get them under control.

I had my first injections back on May 4th and so far they have really helped. Although my migraines have not completely disappeared as of yet, they have been less intense and a lot less frequent than they were prior to the injections. However, they do say it can take a few rounds before they will know if it will work effectively, so I’m hopeful that they will only continue to improve after my next appointment with neurology in August. Nevertheless, I was much more anxious about what the MRI would [or would not] show than the results of the EEG.

To my surprise, the MRI showed that my brain was fine. There were no brain lesions, tumors, growths, signs of stroke, etc.,  which was really good news. The rest of my head, though, not so much…

MRI of the Head/Brain W/O Contrast

FINDINGS:

The brain parenchyma is unremarkable. The diffusion weighted images demonstrate no evidence of recent infarct.No evidence of hydrocephalus. The pituitary gland, pineal gland, and corpus callosum regions are normal in appearance. There is no intracranial hemorrhage. No extra-axial fluid collections are present. The orbits, cavernous, and para cavernous regions are unremarkable.

The paranasal sinuses demonstrate complete opacification of the right
maxillary antrum, with maxillary sinus wall thickening, suggesting chronic sinusitis. There is a rim of T1 shortening and associated susceptibility within the mucosal thickening, which could represent inspissated mucus or possibly allergic fungal disease. There is no associated expansion or erosive change identified to suggest mucocele. There is a retention cyst within the right sphenoid and likely along the roof of the left sphenoid. Mild mucosal thickening within the left maxillary antrum.

The calvarium, skull base, and craniocervical junction are preserved. Normal vascular flow-voids are identified.

Impression: 

  1. Unremarkable MR appearance of the brain without contrast.
  2. Paranasal sinus disease as described, including complete opacification of the right maxillary antrum, with suggestion of chronic maxillary sinusitis. Ring of T1 shortening and susceptibility within the right maxillary antrum could represent inspissated mucus or possibly allergic fungal disease. 

So what does all this mean? According to the neurologist, it means that I needed a quick referral to an ENT for evaluation. Great – another new doctor.


At the same time all this was going on, I also had two other MRIs  (aside from the one on my brain)  to evaluate the acute pain I suddenly was having on my right side that further radiated down into my pelvic region. Although the first MRI was supposed to be on both my abdomen & pelvis, it only was approved as an abdominal MRI. Not surprisingly, since it didn’t show anything other than the vascular compressions seen on my earlier CT scans, they ended up having to order another MRI of my Pelvis a few weeks later. Thankfully, given the amount of time that had passed between tests, the concern about appendicitis had pretty much been ruled out.

MRI of the Pelvis W/ and W/O Contrast

Findings:

Pelvis Mesentery: Small quantity of free fluid within the posterior dependent pelvis, primarily within the rectouterine pouch of Douglas with trace fluid also adjacent to the lower aspect of the uterine fundus.

GI:  Small tubular structure originating from the base of the cecum, just below the terminal ileum, with location and appearance most consistent with the appendix, normal in appearance and size (for instance image 41 series 6). No abnormal
surrounding T2 signal and no abnormal contrast enhancement about the terminal ileum or appendix region. Normal appearance of the terminal ileum (for instance image 37 through 39 series 6).

Uterus: Uterus is normal in size and appearance, with normal anteflexed uterine
fundus. Cervix is normal in appearance by MRI evaluation.

Adnexa: There is a 1.8 cm peripherally enhancing cyst in the right ovary, with mild heterogeneous internal T2 appearance, with normal internal T1-weighted isoechoic appearance. Several small follicles in bilateral adnexal regions.

Impression:

  1. Small 1.8 cm peripherally enhancing cyst in the right ovary. Small quantity of free intrapelvic free fluid. Right ovarian cyst may represent a previously ruptured right follicular cyst. Per current radiology criteria no further specific follow-up for this right ovarian cyst is required.
  2. No MRI findings to indicate appendiceal pathology, including no abnormal edema or enhancement surrounding the cecum or appendix.

Although it states in the report that no further up was needed for the ovarian cyst according to radiological criteria, my gastroenterologist disagreed and, therefore, referred me to my gynecologist for further evaluation.


At first, my gynecologists wasn’t extremely concerned about the findings of the report. However, there was some concern was that the cyst did have a heterogeneous appearance, although this could mean anything from being benign growth all the way to cancer. He sent me for a follow-up transvaginal ultrasound, which he said was the preferred method for evaluating ovarian cysts, just to be safe.

US Pelvic Transvaginal

Findings: 

The myometrium is heterogeneous but no distinct mass. The endometrial stripe is within a normal range for age. There is a small amount of free fluid. Both ovaries are well-visualized. In the right ovary, there is a partially collapsed but otherwise simple appearing cyst in the right ovary, which on my repeat measurement is 17 x 9 x 15 mm in size. The larger area measured by the technologist is not well-defined and likely includes normal variant parenchyma. Otherwise, there are simple follicles

Both ovaries are well-visualized. In the right ovary, there is a partially collapsed but otherwise simple appearing cyst in the right ovary, which on my repeat measurement is 17 x 9 x 15 mm in size. The larger area measured by the technologist is not well-defined and likely includes normal variant parenchyma. Otherwise, there are simple follicles under 1 cm in size in both ovaries.

Impression:

  1.  17-mm partially collapsed but otherwise benign-appearing right ovarian follicle.

The good news was that the cyst itself was benign. The bad news, however, was that the cyst had virtually stayed the same size during the month and a half between testing, despite being collapsed in both scans. Basically, the cyst seemed to be refilling itself over and over with fluid (likely blood), thus explaining the free fluid throughout my pelvis that should not have been there.

The doctor gave me a shot of Depo-Provera, which contains the hormone progestin, in hopes of getting rid of the cyst since it likely wasn’t going to go away naturally on its own. If the shot didn’t help to get rid of the cyst in 6 weeks, the doctor informed me that it would have to be surgically removed. Great

Lucky for me, however, the Depo did its job and the cyst was virtually gone during the next transvaginal ultrasound.


Just as one surgery was crossed off my list, another one was added. After I met with my new ENT about the results of my head MRI, he ordered a CT of the head to confirm the extent of the damage marked in my first scan. As expected, it only accentuated the fact that I would need surgical intervention on my sinus cavity.

CT Sinus Complete

Findings:

The sinuses are normally developed bilaterally.

The frontal sinuses are normally aerated. Minimal thickening cannot be excluded in the left ethmoid sinus. Right ethmoid sinus is normally aerated.

There is marked diffuse opacification of the right maxillary sinus, consistent with marked chronic inflammatory disease, and associated thickening of the inferior and lateral maxillary sinus bony wall. Small areas of probable calcification representing debris are noted within the chronic inflammatory tissue.

Minimal thickening is noted involving the left maxillary sinus.

The right ostiorneata complex is obstructed. The left ostiomeatal complex is patent.

Mild thickening is noted in the right component of the septated sphenoid sinus .

There is very minimal undulation of the nasal septum, but no significant deviation.

I just had endoscopic sinus surgery this past Friday, which including a septoplasty, turbinate reduction, antrostomy, and sinusplasty. So far, everything has been going good, except that the recovery has been much harder than I had originally expected. I’ll go over all the fun details, with pictures, hopefully in my next update.

Although all of this may seem like a lot, I still haven’t gotten to the best part – A new vascular surgeon and substantially larger surgery here in the near future – but that is definitely a story I’ll have to share another day.

ihc-20quotes-never-give-up

What Is The Best Way To Cope With Pain?

Pain is defined as being an experience of both physiological and psychological discomforts marked by unpleasant or uncomfortable sensory symptoms resulting from some sort of damage or injury (Gurung, 2014). The origin of pain can come from a variety of sources and there are numerous ways that individuals can cope with pain, consisting of either psychological or biological interventions. Certain pain management therapies may work better than others depending on the source and duration of pain, as well as an individual’s tolerance or threshold for the pain. According to Gurung (2014), there are three primary classifications of effectively managing pain: physiological treatment, psychological treatment, and self-management techniques.

Physiological techniques for managing pain, for instance, often involve the use of pharmacological or chemical management methods, traditional or holistic treatments (e.g. acupuncture), and surgical interventions. Medicinal therapies are generally one of the first approaches used for pain management, particularly if the ailment is caused by acute pain triggers (e.g. broken bones, sprains, illnesses, etc.), and generally comprise of pharmaceuticals called nonopioid, opioids, and adjuvants. Adjuvants are medications that are prescribed to manage pain but are not solely listed for that purpose. These medications are used primarily because they have shown some effect in helping to manage pain, although they may elicit different physiological responses. Some common example of adjuvants includes benzodiazepines, corticosteroids, antidepressants, and local anesthetics (Gurung, 2014). Nonopioids, on the other hand, include many of the over-the-counter pain relievers, such as ibuprofen, aspirin, or acetaminophen. According to Gurung (2014), “these medications act locally, often at the site of pain” (p. 291) and provide quick-acting, short-term relief in milder forms of acute pain. However, nonopioid drugs are generally not recommended for continued use due to the many long-term side effects associated with these drugs and their inability to maintain pain relief over time.

A stronger category of medication, known as opioids or narcotics, are much better suited for more severe pain management, particularly for those undergoing a surgical procedure, have suffered a severe illness or injury, or are living with a chronic or debilitating illness. Some well-known examples of opioids include oxycodone, codeine, morphine, and methadone. Opioids are the drug of choice for moderate to severe pain, given their level of effectiveness. Morphine, for example, works by binding to the “receptors in the periaqueductal gray area of the midbrain and produces pronounced analgesia and pleasant moods” and mimics the body’s natural response to coping with pain (Gurung, 2014, p. 291). However, opioids come with their own set of side-effects that are often much more severe than nonopioid medications. For instance, there is a much higher risk factor for overdose or addiction, and individuals who take opioids for chronic pain management often build up a large tolerance to these types of medications. Therefore, in order to gain the same benefit, patients also need to increase the dosage of the drug which places them even further at risk for the potential of overdose or addiction. Nonetheless, the controversy over the effects of long-term opioid use is a hot topic of debate in both the medical and chronic illness communities.

Still, there are a number of physiological techniques, outside of medications, that also assist with pain management strategies. Some examples include acupuncture, surgical interventions, and the use of either hot and cold compresses (and even alternating the two). Acupuncture, for example, works to manage pain by releasing blocked energy associated with pain and has been used in Traditional Chinse Medicine for years (Gurung, 2014). Alternately, surgical treatments can also help in decreasing levels of pain by removing the conduction of many of nerve fibers throughout the body that directly or indirectly transmit pain signals to the brain. However, while surgical approaches typically provide relief of pain for a period of time, improvement does not seem to provide a long-term cure since nerve fibers’ have the ability to regenerate. Still, while the majority physiological techniques offer relatively good methods in managing acute forms of pain, psychological strategies for the management of pain are likely to be more effective for handling chronic forms of pain.

Research into various psychological techniques shows that many of the pain pathways found within the human body are directly linked to the brain, ensuring that pain is very much a psychological process in addition to being a physiological one as well. A person’s mood can greatly impact how individual’s cope with or experience pain and altering one’s cognitions about chronic pain is, therefore, detrimental to obtaining control of individual levels of pain. For instance, when a person is undergoing chronic stress or is depressed, they are likely to feel more pain. According to Gurung (2014), “negative mood states can lead to biased forms of thinking. These cognitive biases can accentuate the feelings of pain and need to be modified” (p. 294).  Often, these behavioral modifications come from the use of psychological techniques (e.g. hypnosis, distraction methods, and relaxation techniques) in a similar manner to the practices associated with coping skills for dealing with stress. Distraction techniques, for example, are helpful in handling pain because it diverts attention away from the problem, similar to stress management techniques, and includes the use of some common practices like guided imagery, meditation, or watching television, reading a book, or talking with a friend over the phone. Likewise, biofeedback is also helpful in identifying pain triggers through observing physiological responses to pain through the use of machines or computers and then teaching relaxation techniques in order to assist individuals in gaining control of their physiological reactions to pain.

Although both psychological and physiological approaches to pain management procedures are helpful in their own ways, neither necessarily define the “best method” for handling pain—at least, not alone. Essentially, the primary problem in defining a standard method of pain management is the fact that the experience of pain is mostly subject. Although tests are available to measure specific fragments of pain, currently there is no exam available that can objectively measure pain with any amount of accuracy. Also, since both physiological and psychological factors influence the involvement of pain, it’s hard to distinguish which variables are positively or negatively altering elements of pain and individual levels of pain can change day-by-day. Given the number of factors involved, perhaps a better method for managing pain is to utilize a dual approach by combining both psychological and physiological techniques.

One way to combine both pain management strategies is through a technique known as self-management, which has been particularly supportive of individual’s living with chronic episodes of pain. Self-management programs are defined as “treatments for pain relief that make the patient with chronic pain the one with the most responsibility for making the change rather than the doctor or the health professional staff” (Gurung, 2014, p. 452). Self-management programs for chronic pain are effective because they focus on the emotional aspects of pain, outside of the physiological response, by teaching patients to change their thoughts or behaviors to better cope with their pain – mainly by focusing on various strategies to improve one’s overall quality of life. According to Gurung (2014), the main goals of self-management programs are to:

  1. Provide skill training to divert attention away from pain;
  2. Improve physical condition (via physical reconditioning);
  3. Increase daily physical activity;
  4. Provide ways to cope more effectively with episodes of intense pain (without medication);
  5. Provide skills to manage depression, anger, and aggression; and
  6. Decrease tension, anxiety, stressful life demands, and interpersonal conflict. (p. 297).

Gender Bias of Pain:

It’s important to point out a very significant problem currently plaguing patients across the country — the gender bias in medicine. Although this problem is not exclusive to pain management, the gender bias in medicine is alarming because many women are often left without the proper care essential to maintaining a good quality of life.

It’s become far too common that women’s complaints of pain or illness are minimalized by the medical professionals they turn to for help, often implying that women are overly dramatic in their interpretations of pain. Doctors often label many of the pain symptoms found in women as being psychosomatic or “all in their head” when a diagnosis is not easily obtained. This bias becomes even more evident in women who have chronic pain, who continue being called a “drug-seeker” when asking for pain relief. “Women are more likely to have chronic pain conditions that are more difficult to diagnose and treat (TMJ Disorder, fibromyalgia), and in many cases, these are treated as mental or hormonal rather than as a disease or disorder” (Stacey, 2012). Likewise, many doctors still foster the ideology of the gender bias by suggesting that women are affected by pain harder than men.

According to Gurung (2014), “women reported significantly higher pain in most categories with the most significant differences in patients of the musculoskeletal, circulatory, respiratory and digestive systems, followed by infectious diseases, and injury and poisoning” and “men report less pain, cope better with pain, and respond to treatment for pain differently than women” (p. 274) However, at least in their initial presentation, these statements are somewhat misleading. At best, research is relatively and widely varied. Recently, an article I came across by Dusenbery (2015) called Is Medicine’s Gender Bias Killing Young Women? described this phenomenon in detail:

This pervasive bias may simply be easier to see in the especially high-stakes context of a heart attack, in which the true cause usually becomes crystal clear—too often tragically—in a matter of hours or days. When it comes to less acute problems, the effect of such medical gaslighting is harder to quantify, as many women either accept misdiagnoses or persist until they find a health care provider who believes their symptoms aren’t just in their head. But it can be observed indirectly: In the ever-increasing numbers of women prescribed anti-anxiety meds and anti-depressants. In the fact that women make up the majority of the 100 million Americans suffering from (often under-treated) chronic pain. In the fact that it takes nearly five years and five doctors, on average, for patients with autoimmune diseases, more than 75 percent of whom are women, to receive a proper diagnosis, and that half report being labeled “chronic complainers” in the early stages of their illness. Then there are the diseases, like chronic fatigue syndrome and fibromyalgia, that exist so squarely at the overlap of the Venn diagrams of “affects mostly women” and “unknown etiology” that they’ve only recently begun to be recognized as “real” diseases at all.  (para. 20)

There are some valid explanations for why pain across gender is inconsistent. In a study by Hamberg, Risberg, Johansson, & Westman (2004), for instance, it was found that “proposals of nonspecific somatic diagnoses, psychosocial questions, drug prescriptions, and the expressed need of diagnostic support from a physiotherapist and an orthopedist were more common with females” (para. 3). However, laboratory tests, physical examinations, diagnostic testing, and pain management were offered to men more often than it was for women patients. Additionally, the differences offered in treatment could result in the many inconsistencies demonstrated throughout the literature as to how men and women are different when it comes to pain. Furthermore, the gender difference may be the direct result of our modern culture expect men and women to experience pain. We often encourage women to express their feelings about pain, yet make them feel like they are crazy or are behaving like a hypochondriac in following the expectation. Alternately, society tells men to hide their emotions. So of course, it’s easy for “science” to say that women have more reported pain than men because females are more likely to confess about their experiences of pain, skewing the results and furthering the gender bias. At the end of the day, I do believe that Dusenbery (2015) stated it best by saying, “call me crazy—hysterical, even—but I don’t think you should have to feel that empowered just to receive proper medical treatment” (para. 20).

References

Dusenbery, M. (2015). Is Medicine’s Gender Bias Killing Young Women? Retrieved on Feb 16, 2016, from http://www.psmag.com/health-and-behavior/is-medicines-gender-bias-killing-young-women.

Gurung, R. A. (2014). Health Psychology: A Cultural Approach (3rd ed.). Belmont, CA: Wadsworth.

Hamberg, K., Risberg, G., Johansson, E.E., & Westman, G. (2004).  Gender bias in physician’s management of neck pain. Journal of Women’s Health & Gender-Based Medicine, 11(7): 653-666. doi: 10.1089/152460902760360595.

Stacey (2012). Is There Gender Bias in Pain Management? Retrieved on February 16, 2016, from http://www.tmjhope.org/gender-bias-pain-management/


To find out how you can receive FREE online therapy to manage chronic pain, please visit the following article on the Better Health website:

https://www.betterhelp.com/advice/therapy/get-free-online-therapy-should-you-use-free-counseling/