Snoring, Recurring Chronic Sinusitis and Concha Bullosa
Snoring and Mild Apnea
I snore at night and never knew it until I got married. It was my wife that suffered the most from the noise; I usually slept right through. I didn't know that I snored. Looking back now I understand some other symptoms that I had that were clearly related to my snoring.
I would awake in mornings feeling tired. I would just lie in bed upon waking and still felt exhausted like after a marathon or long bike ride. While not breathing hard or struggling for breathe, I just felt muscle-tired and weak. "Deprived of oxygen all night long" actually makes sense now although I would not have known to use those words exactly. It was not as I had felt suffocated in any way but I always had a fan on or window open for fresh, moving air. Without it I seemed quite sensitive to re-breathing my own air.
When I did finally get up in the morning I would just sit on the edge of the bed for a half hour at least, waiting for my energy levels to come back. My energy levels would restore eventually and after first coffee and I'd be fine the rest of the day and into the evening.
I thought all of this was because I worked night-shift from 4-PM until midnight, often having to stay later until 2 or 3-AM. I did this for nearly 17 years. It was after I got married that I left that life and became a diurnal creature of the day again. It was then that I was informed of my snoring by my sleepless partner.
Sinusitis, Snoring and Always Tired
I also had had recurring bouts of sinusitis, bronchitis that often led to pneumonia. This had gone on for many years; it was just part of my life for nearly two decades. I was accustomed to it and thought this was normal. It was an unusual winter if I had less than two or three major bronchitis and/or pneumonia incidents. I would receive medication for it and get well, only to get sick again a month after the last of the medication was taken. While usually this occurred during the winter months I often had bronchitis and mild pneumonia even in the spring and summer too.
I even had a doctor or two inquire into what line of work I was doing; -did I work with sick patients or the elderly, etc. My recurring sinusitis was slightly worrisome to more than a handful of general family practitioners over the years. More than once I ended up having an MRI of my chest and lungs (and once even being told that I might even have tuberculosis) but that turned out to not be the case. I had various aspect X-rays taken of my skull and apart from a mild deviated septum (‘crooked nasal bone’) nothing was notably amiss. Mostly, if I ‘got well’ the case was dropped and I continued on my way.
I was sent to a sleep clinic here in Toronto once to find out the cause of the snoring. It was revealed that yes, I snore and that I also have mild apnea. –I would ‘stop breathing’ for several seconds, once or twice per hour. It was not so acute that it required any intervention. Some apnea suffers will ‘stop breathing’ for nearly a minute at a time, and in acute cases up to dozen or more times per hour! These people are severely sleep-deprived, moody, often overweight and other long-term health complications. They are also likely prone to ‘falling sleep’ inappropriately during the day. Often, persons with acute apnea have their Driver’s License taken away for safety reasons. –They might ‘fall asleep at the wheel.’
Apart from that, there was nothing overly concerning and we would have to investigate other reasons for my snoring and sleep deprivation. What to do in order to control the degree of apnea that I do have were discussed. Appliances range from a device that through the action of suction, secures the tip of the tongue and clips onto the front teeth. This device is worn only at night and holds the tongue from moving towards the back of the throat, often a cause of restricted air flow and subsequently, snoring.
Surgery to Stop the Snoring?
Another surgical intervention option is the 'trimming' of the palatal tissues, something that more than one doctor advised me against. While loose palatal tissue does vibrate when one snores, ‘trimming’ this is first of all, an exceedingly painful procedure post-operatively and of limited effectiveness in all but the most severe cases does it provide actual relief (only about 30% experience any reduction of snoring.)
And lastly, a contraindication of a surgically trimmed palate is very often the patient experiences pronounced difficulty swallowing food and drink. This is lifelong, and can be rather pronounced. The ‘gag reflex' is due to excised palate tissue and this most definitely does not sound appealing as described, then or now.
It wasn’t until having come to my family doctor a second or third time in as many months for yet another bronchial congestion and sinusitis complaint that he suggested a new course; a CT Scan of my skull. This had never before been suggested before as part of my investigative therapy or treatment.
The Computer Tomography (CT) Scan is a ‘low-level X-ray’ that reveals soft tissue structures whereas the hard X-ray only reveals only the bone structure. The findings were ...unexpected. I had a condition and structure called “Concha Bullosa.”
Concha Bullosa and Sinusitis/Snoring Connection
The recurring bouts of sinusitis should have been a clue. Concha Bullosa is a common anatomical variant for which there is a strong association with what is called a contralateral deviation of the nasal septum. In short, the ‘crooked nasal bone’ revealed in the X-rays of the past should have been a clue to next perform a ‘soft X-ray’ (CT Scan) to examine any deviation of the soft tissues and mucosa of the concha of the nasal region.
An interesting and simple test for blockage is also rather revealing. Cover one nostril with a finger and inhale deeply through the other nostril while holding the mouth shut. Then repeat the procedure with the other nostril. A physical ‘blockage’ or restriction in either nostril would be revealed if you feel that one nostril ‘takes in more air’ than the other nostril. The difference between the two nostrils can be substantial.
I explained that I have ALWAYS had this difference in airflow, that one nostril was supplying about half as much airflow as the other. I had to sleep on the side of the ‘greater airflow’ or I would gag for air in the night. I had lived that way for many years, a decade or more. Apart from normal deviate septum (which also affects airflow sightly, and is normal) this was a vital clue to other obstruction. Apparently, all those doctors had assumed that the ‘blockage’ was mucus or soft-tissue swelling and not something more ‘physical’ like an over-sized nasal turbinate.
Medically, Concha Bullosa means and refers to "an enlargement of the nasal turbinate.”
“Concha” refers to the turbinate, particularly the middle turbinate (See image above.) “Bullosa” refers to the bubble-like air-filled structure.
The turbinate are normal structures of the nasal region. Enlargement causes obstruction and restricted airflow. If the turbinate is hollow (sometimes they are) they can contain mucus which becomes infected, when it leaks out it and gets into the lungs, it can cause sinusitis. If I recall the verbal consultation correctly, medications will alleviate the symptoms of bronchitis but will not effectively 'sanitize' the infected mucus in the hollow turbinate. This is a ‘typhoid Mary’ in effect. –It will ‘leach’ infected mucus into the nasal cavities and these are expelled via the nose, swallowed harmlessly, or inhaled where it rapidly becomes chronic sinusitis in the warm, moist conditions of the lungs.
It is a simple case of reducing the concha bullosa by surgery to correct this deviation and open up the turbinate, as well as the airway. My surgeon explained it for me in simple layman terms. He explained the ambulatory surgery this way: (paraphrased)
“...think ‘hard-boiled egg’ in the nasal canal. (He will) ...go in, break the bottom of the egg and remove the bone. Next, scrape-out the contents of the egg and then break through the top of the shell to open the airway.”
He explained that he would then pack the nasal cavity with a length of gauze that would be taped in place to the external naris (outside base of the nose,) and that I would have to endure this arrangement for 24 hours. This would be all be removed the next day and if I did okay with that, they would allow me to go home.
He told me on the morning of surgery that he was going to ‘clean out’ both nasal passages. That had been my hope from the time I was diagnosed, that both sides would be done.
I also had a polyp or two in one nasal passage, he told me. Harmless, these would be removed too since he was in there anyway. Below is a video which graphically depicts what was done for me. This is a bit unsettling folks if you are squeamish you might want to forgo this. You have been warned...
The Day of Surgery: Concha Bullosa Removal
The day of surgery came and it was actually quite pleasant. It would take perhaps 45-minutes I had been told although I might be under general anesthesia for several hours post-operative.
I awoke with the aforementioned gauze packing and a taped bandage covering the base of nose and adhered to my cheeks. My face felt quite ‘full’ because of the gauze stuffing. I had to wear the gauze wadding up both nostrils for 24-hours to control bleeding.
Returning the next day to have these extracted went fairly well. It was not painful but it was unpleasant and grotesque in the utmost to have a meter long strip of pinkie-finger diameter bloody gauze pulled from each nostril. There was some mild bleeding and a bit of cleaning-up to follow. A short time later, I was discharged and went home. Over the course of hours and days, various large and disgusting blood clots would be discharged, -providing me with indescribable relief. While most unpleasant, this and the telling of it, the rewards for the suffering were innumerable!
The weeks held return visits for follow-up examinations. All was well. I could BREATHE! I would inhale and it would fill my head! I could HEAR the air rushing into my skull! When I speak I notice that my voice has a heretofore unknown ‘hollow’ quality to it. It is like wearing a motorcycle helmet with the face-shield down while speaking. Others probably don’t notice the difference in my voice, but I do. I liken it to having a ‘Darth Vader’ voice.
When I inhale deeply the improved airflow and increased volume actually makes the roots of my upper teeth ache a little bit. –I told my physician/surgeon this and suggested that this anomaly was ...going to feel *really magical* when winter came and it is minus 30 degrees outside! He laughed of course.
His questions were more of how was I sleeping. -I was sleeping quite well, awakening more rested than I have been in years. I could awaken and be on my feet, dressed and ready to meet the day within minutes. Not since my 20s maybe have I been so rested.
Clearly the obstruction, reduced oxygen flow and the apnea-like conditions that were the cause of my snoring having been fixed. I was returning to a healthier, more normal state of sleeping. According to my wife, the snoring has been reduced to practically nothing. I still ‘snort’ or ‘whistle’ from time to time but if she nudges me and I reposition myself, it usually goes away. Before, this would not improve the noise situation despite countless nudges and prods. And best of all, that fall and winter season I did not have even one outbreak of sinusitis, bronchitis or anything! I did have one 'late spring' cold which lasted maybe 7 days, but it was nothing compared to previous years. It was the first time in probably a decade that I went all winter without incident of bronchitis and sinusitis, -I cannot put into words what an achievement this was for me!
Four years later now, I do still need or want to have a fan on low when I sleep to ‘move the air around.’ It may be as much a comfort thing borne of habit to know that there is air for me to breath, even if my face is not directly in the breeze all night long. I am not snoring and I am still waking up for the greater part, refreshed and energized. For me, the removal of the concha bullosa was highly effective and has greatly improved the quality of my sleep. -And my wife's.