Dr. Rajendran Dinesh Kumar

Nasal polyps recur after FESS because surgery addresses the anatomical result of the inflammatory process  -  the polyps themselves  -  but does not alter the underlying mucosal inflammatory environment that caused them to form. The dominant inflammatory mechanism in most nasal polyp disease is eosinophilic inflammation, often with an allergic or immune component, and this mechanism continues to drive new polyp formation after surgery if it is not treated. The most effective strategy for reducing recurrence after FESS is consistent use of topical nasal corticosteroid sprays post-operatively, initiated as soon as healing allows and continued long-term, combined with formal allergy evaluation. If a specific allergen sensitisation is identified as a driver of the chronic nasal inflammation, addressing it through allergen avoidance and where appropriate allergen immunotherapy can substantially reduce the rate at which polyps regrow. The patients who do best in the long term after FESS for nasal polyps are those who are compliant with post-operative medical management and whose allergic component has been identified and treated. Patients who have surgery and then discontinue nasal steroids, or whose allergy has never been evaluated, tend to experience earlier polyp recurrence.

Eustachian tube dysfunction presents in two clinically opposite forms that share some overlapping symptoms but have entirely different underlying mechanisms and require different management. Obstructive Eustachian tube dysfunction is the more common presentation  -  the tube fails to open normally during swallowing, yawning, or jaw movement, which means the middle ear cannot equalise pressure with the atmosphere. The result is negative middle ear pressure, ear fullness, muffled hearing, and in chronic cases, accumulation of fluid in the middle ear (otitis media with effusion, or 'glue ear'). Patulous Eustachian tube dysfunction is the opposite  -  the tube stays abnormally open rather than closing at rest. Patients with patulous ET dysfunction experience autophony, which is hearing their own voice and breathing with abnormal loudness and resonance inside their ear, a sensation often described as echoing or reverberating, and which is both distressing and disorienting. The diagnosis is confirmed by specific tests including tympanometry and endoscopic nasopharyngeal assessment. Treatment for obstructive ET dysfunction focuses on reducing mucosal inflammation through nasal steroids and allergy management, with balloon Eustachian tuboplasty or grommets for refractory cases. Treatment for patulous ET dysfunction is completely different  -  focused on increasing Eustachian tube mucosal bulk or resistance  -  and the distinction between the two must be made before any treatment is initiated.

Balloon Eustachian tuboplasty, or BET, is a minimally invasive endoscopic procedure that addresses Eustachian tube obstruction directly from within the tube itself. Using a thin catheter introduced through the nose and positioned at the Eustachian tube opening in the nasopharynx, a small balloon is inflated within the tube for approximately 2 minutes at low pressure. This dilates the tube's lumen, disrupts the scar tissue or mucosal changes causing obstruction, and improves tube function and pressure equalisation. BET is performed under general or local anaesthesia, typically as a day procedure, and most patients notice improvement in ear pressure, fullness, and hearing within days to weeks. It is considered when: Eustachian tube dysfunction has been confirmed by tympanometry and clinical assessment, conservative management including nasal steroid therapy, allergy treatment where allergy is present, and a trial of the Valsalva manoeuvre has not produced adequate improvement, and the patient's symptoms are significantly impacting quality of life. BET is not a replacement for grommet insertion in all cases  -  grommets ventilate the middle ear from outside the Eustachian tube and are appropriate for different presentations. The choice between BET and grommets depends on the specific pattern and severity of ET dysfunction in the individual patient.

Recurrent sinusitis that responds to antibiotics only to return within weeks is the pattern that most clearly suggests an underlying allergic component, and in Bengaluru, where house dust mite, cockroach, and Parthenium sensitisation are highly prevalent, it is one of the most common presentations I see at Trustwell Hospitals. The mechanism is straightforward: allergic rhinitis produces persistent mucosal inflammation and oedema that blocks the sinus drainage passages, creating conditions in which bacteria thrive. Each antibiotic course treats the superimposed bacterial infection but leaves the underlying inflammatory environment completely unchanged, which is why the infection returns. Identification of the specific allergen driving nasal inflammation through skin prick testing and specific IgE measurement  -  and then addressing it through allergen avoidance strategies and appropriate pharmacotherapy  -  reduces the frequency and severity of sinusitis in most patients. For patients whose symptoms remain inadequately controlled despite optimal medical management, FESS improves sinus drainage surgically. But for many patients with allergy-driven recurrent sinusitis, treating the allergy eliminates the need for sinus surgery, which is the preferred outcome for everyone involved.