This post is mostly a self check in on my progress dealing with GERD/LPR.

Things that work for me

Elevate head of bed I initially elevated the head of my bed on 6in cinder blocks, but my boyfriend complained, so I swapped them out for 4in bricks.

Pepcid or TUMs as needed 5mg Pepcid or 500mg TUMs will generally take care of any acid reflux.

Add complex carbs. Adding potatoes, whole grains, or beans/legumes helps satisfy my hunger and absorb acid, preventing reflux.

Cut out dairy and fatty foods Ice cream, soft cheeses, cow’s milk. Fatty cuts of meat. Peanut butter.

Cut out obvious trigger foods Tomatos, citrus, chocolate, caffeine, alcohol.

Fast for 3-4 hours before bed

Things that do not work for me

PPI I felt very bloated and slow digestion after a month of PPI)

Inclined pillow I always slide or roll off the pillow during the night.

Things to try

Take a walk after eating I’ve noticed my GERD has worsened over the last year as my physical activity has been reduced due to quarantine and working from home.

Reduce sweets I’ve been making a lot of oatmeal cookies and banana bread during quarantine, but I’m suspicious that either the fat or the sugar is triggering reflux.

Reduce fried potatos French Fries When I’m eating out, I’ll often try to get complex carbs by eating French fries. But maybe the fact they they are fried makes them do more harm than good. Try avoiding French fries.

Salad dressing I try to eat salads as a safe food, but most salad dressings seem to be either very creamy or very acidic. Try asking for a simply olive oil dressing.

Reduce liquids with meals Drink water after meals and limit consumption during.

Get a bravo study This is a study where a temporary pH monitor is implanted at the top of the throat to test whether GERD/LPR symptoms correlate with acidity.


Posted by Abraham

Continued from Part 2.

Turbinate reduction surgery

First, a digression. Midway through grad school, my anxiety shot through the roof and I started having panic attacks every day. Minor panic attacks were nothing new to me. I've struggled with some level of social anxiety for as long as I can remember. Raising my hand in class or meeting someone new would always send me into an anxious spiral. During grad school, anxiety over my thesis and ultimately the direction of my life become overwhelming, and I became constantly anxious.

Most of all, I was afraid that I would need to start an anti-anxiety medication. Looking back, I had no reason to be afraid, but I had built up the idea of taking medication as an admission that I was hopelessly ill. Eventually, after struggling with this for over a year, I decided that there was no way medication could be worse than what I was going through, and I took a leap of faith. helped. It was a sign of maturity, not of failure, to recognize an issue in my life and do what it took to resolve it.

In the same way, nasal surgery has been in the back of my mind for over a year as my doctor and I have explored medical treatments for my nasal obstruction. But after 6 months of steroid sprays and rinses and various allergy medications, I was still sleeping poorly and felt congested all the time. Just like in grad school, I catastrophized. What I feel like this for the rest of my life? What if I need surgery? What if I get an infection? What if I have to spend time in the hospital? But eventually, just like with my anxiety, I came to believe that any temporary pain I might have with surgery couldn't possibly be worse than the suffering I was enduring without treatment.

So on the morning of my surgery I was actually quite calm when friend dropped me off at the outpatient surgery center. I checked in and filled out a standard set of dull medical forms, trying not to think about being sedated and dismembered.

Let me back up a bit. Inside the nose, there are bony structures called turbinates which protrude into the nasal cavity. Turbinates have a soft mucosal lining which expands when you have a cold or allergies. If you have genetically large turbinate bones (like me) and/or have chronic allergies (like me), the nasal airways can become chronically obstructed. For me, this resulted in poor sleep and low energy during the day. After reading patient stories on reddit and watching youtube videos, I was pretty sure I needed a turbinate reduction surgery, and my ENT agreed.

Back at the surgery center, I am lying on the prep bed in a hospital gown, an IV in my arm, and the nurse is rolling my bed into the operating room. With her help, I move to the surgery bed while forcing conversation with the anesthesiologist about my work. Are you working from home a lot? Yes. What do you do? I work on medical ultrasound R&D. Did you study that? No. I studied astrophysics. There's actually a lot of overl...

Suddenly I am in a new bed in a new room, lightheaded, coughing up blood. The nurse hands me a plastic bag to cough into. I feel fluid in my airway. I don't really understand what's happening. I'm coughing and doing what I'm told. The anesthesiologist comes in and says something about a rare complication. I'm coughing more. Now my nose is bleeding. The nurse asks if I want to watch TV, I say no, I just want to listen to some music from my phone. My blood pressure and oxygen are low. No time to think. I cough and cough.

I was originally told I'd be able to leave mid morning, but it's past noon and I'm still in the recovery room. The doctor comes back in to check on things, and explains what's going on again now that I'm more cogent. I had a rare complication known as negative pressure pulmonary edema. If a drop of blood or saliva hits the vocal cords, they can spasm, blocking your airway to protect your lungs. If you are awake, you can cough it up and continue breathing. But if you are unconscious, then you can't cough, so you could suffocate.

To avoid this, patients are typically intubated during general anesthesia. In rare cases laryngospasm can happen after the breathing tube is removed, but before the patient fully awakes, which can result in the patient effectively “breathing” in fluid from the alveoli because the airway is blocked. This occurs due to the negative pressure created during inspiration relative to the surrounding tissue. According to my anesthesiologist, this occurs in 0.1% of all surgeries, though [1, 2] quote up to 10% of ENT surgeries due to the higher incidence of bleeding around the upper airways. In fact, risk factors include being young, male, and otherwise healthy. (Less healthy patients are less able to produce as much negative pressure during inspiration against closed vocal folds.)

It's been almost a month since the surgery and here is where things stand now: My nose is producing a lot more mucous than normal due to the trauma from surgery, and I am cleaning it regularly with nasal saline rinses and sprays. The constant sniffling is frustrating, especially at night, when the mucous dries, and partly obstructs my nostrils. But I've been back to my ENT twice for quick cleanings, and after each one my nose has felt much clearer. He says that it may take 2-3 months for the sniffling and inflammation to completely subside, so in the mean time I'm living with saline rinse spray bottly and a pack of tissues. But I'm already sleeping and breathing better than before the surgery, and I know/hope/pray things will continue to improve!


Posted by Abraham

Continued from Part 1.

Chronic allergies

After getting me started on Flonase, my ENT sent me for allergy testing, which revealed that I have a strong dust mite allergy, but nothing else very significant. My mom reminded me that I was allergy tested when I was little and the results were the same. In fact my parents put hardwood floors in my bedroom instead of carpet when we moved to Portland, though my sister and I switched rooms after a couple years and the carpet never seemed to bother me. I've occasionally woken up with a stuffy nose over the years, but hypoallergenic sheets and pillow cases never made much of a difference.

After a couple months on Flonase, my nose was no better than before, and this was early-COVID so all elective surgeries were still on hold. I was still skeptical that my nasal congestion was due to allergies, but given that the test was strongly reactive I agreed to try Singulair. After a couple weeks I actually felt like my sinuses were clearer and I had more energy during the day. I started lap swimming and running again. I was still fairly somewhat congested at night, so I continued using Breathe Right strips.

The fact that the Singulair helped made me think that allergies really are what's going on. So I started immunotherapy for dust mites with a new under-the-tongue tablet called Odactra. Think of it like allergy shots without the shots. For the first 1-2 months it gave me a lot of inflammation and itching under my tongue, but then my reaction to it subsided completely, which made me think it was starting to work! The literature suggests that the body develops a local tolerance to the antigen after a couple months, and a system response after 6 months to a year (See [1] and [2])

Fast forward to this month, even with Singulair I'm still struggling with nasal congestion at night and sometimes during the day. It feels like it's not working as well as it did a few months ago. So I went back to my ENT and asked to move forward with a turbinate reduction surgery, with the idea that Odactra will prevent them from growing back long term. We decided not to fix my mild deviated septum or valve collapse at this point. I think the evidence really points to turbinate hypertrophy as the leading order issue, and I'd like to avoid septoplasty and rhinoplasty if at all possible.

So that's where things stand now. The turbinate reduction surgery is scheduled for the end of the month, and hopefully it will give me some relief!

Continued in Part 3.


Posted by Abraham

A decade of Breathe Right strips

Maybe 7 or 8 years ago I started notice that I had trouble breathing through my nose while lying in bed at night. It bothered me a little bit, but not too much. I generally slept well and had plenty of energy during the day. I didn't think much about it until I saw a TV ad for Breathe Right strips, basically sticky strips of plastic that you put across the front of your nose to pull open your nostrils. I bought a pack at CVS and started using them at night. They definitely helped me breathe at night, and I became a convert.

Fast forward to a year ago and I'm not sleeping well. I'm falling asleep alright and sleeping through the night, but I'm waking up tired. My nose is feeling congested during the day too, even though I'm not sick. I'm struggling to make it through the day without an afternoon nap or a cup of coffee. (I've never been a coffee drinker, so caffeine is new to me, lol!) Some days are worse and some are better. Some days I get to work and immediately want to nap on the sofa in the lobby, but other days  I have enough energy to swim laps at the Y.

I probably should have gone to the doctor at this point, but I have a PhD in Physics and I'm stubborn so I start trying to figure things out on my own. I record my sleep with SnoreLab and find that I've started snoring. I switch from the regular to  extra-strength Breathe Right strips, which helps a bit. I start taking daily Claritin in case I've developed allergies, but it doesn't help. I try taking Sudafed before bed and—wow—it really opens up my sinuses. I wake up really refreshed and energized! That's...good...right? At this point I've done enough googling to know that you shouldn't use decongestants for more than a few days because you can become dependent on them.

I finally see my PCP and he takes one look in my nostrils and says “Your turbinates are really swollen!” “What does that mean? What are turbinates?” I ask. “They're normal anatomy, but yours are really swollen, especially this one,” he says, gesturing to the left side of my nose. “I think you should see an ENT.”

Fast forward a couple weeks and I'm sitting in my ENT's exam room getting a nasal endoscopy, which is fairly tolerable until starts to push the endoscope through the back of my sinus and down to my vocal folds. Eventually he gives the verdict: I have very large inferior turbinates, a deviated septum towards my left side, and some nasal valve collapse. He believes the turbinates are my primary issue, which is consistent with my congestion gradually worsening over a couple years, not preferring one side or the other, and responding to Sudafed.

For now, he says I have to try Flonase for 2-3 months “before insurance will entertain anything else”, but remarks that there a few surgical options to consider if it comes to that. First is an outpatient procedure called turbinate coblation to shrink the inferion turbinates. Second is a surgical reduction of the turbinates  (surgeons use innocent-sounding phrases like “shaving them down”). And last are septoplasty to fix my deviated septum, and even rhinoplasty to strengthen my nasal valve (“Think of it like an internal breathe right strip”).

It's a relief to know that there are physical causes of my congestion, and that there are options to address them. So, perfectionist that I am, I watch about a dozen videos on YouTube about how to correctly use nasal sprays, and start using Flonase twice a day, be continued in Part 2!


Posted by Abraham