Sinus Surgery (3 Weeks)

I’m feeling great.  The only difficult part appears to have been the first 10 days.  Most of that was due to the unexpected bleeding.  I would have probably been feeling pretty good about a week out if that hadn’t happened.  All in all, I would say that the whole experience wasn’t nearly as bad as I was anticipating.

The surgery appears to have been a resounding success.  I can breath better than I ever could before.  As Dr. Dawson promised, my turbinates were a bit swollen at first, but they have shrunk down.  I can breath better now than I could even with judicious snorting of Afrin before.  I was worried a couple times, but it always turned out to be a clot or temporary irritation due to blowing my nose too hard.

I’m still seeing a little blood when I gently blow my nose.  Every day there is a little less.  I’m no longer coughing up things that look like they came out of a horror movie.  That’s probably for the best.  Emily was getting sick of me saying, “hey babe, wanna see something really gross?”  TMI…

In my 3-week post op yesterday, Dr. Dawson said I could go back to normal activities.  He just suggested taking it easy for a while.  No neti pot yet.

An unintended consequence of the surgery is that my neck and back feel a lot better.  I was doing a lot of stomach sleeping presumably because that was when breathing was easiest.  I can now sleep on my back (WITHOUT SNORING!) or my side comfortably.

My advice to anybody contemplating this surgery: do it.  Breathing at night is well worth a week of moderate discomfort.  Next checkin with the doctor is in another 3 weeks.

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Securing THE CLOUD

Dilbert.com

One of the primary purposes for this blog is to talk about information security.  An appropriate first post on the topic is Securing THE CLOUD.

Cloud is one of those words I don’t like to use.  It was drummed up by marketing gurus to make an old idea sound new.  All the cloud means to me is putting your stuff on somebody else’s servers.  Generally that stuff is accessible from anywhere on the internet, although they have coined the term ‘private cloud’ to describe a scenario where access is more limited.  I digress.

As a developer for the cloud, the stakes are high for you.  Customers are entrusting you to protect their stuff which is logically connected every internet user on the planet (potentially sans N. Korea, Iran, China, et al.).

Here is a checklist that I like to think of when I’m evaluating the security of a cloud product.  I suppose you could turn it around and use it as a howto guide.  Just a quick caveat.  I am not a programmer.  I stopped programming as soon as I realized just how bad I am at it.  You know what they say, “those who can’t do manage”.

  1. Guard the front gates with everything you have.  Every restricted-access cloud service sits behind an authentication layer.  That is your first line of defense.  The first line of code on every page (figuratively) should be an authentication/authorization check.
  2. Don’t even think of writing your own authentication system.  Let somebody else do that for you.  Trust me, they are much better at it than you are.  Use Microsoft ID (aka LiveID), Open ID, Google ID, Facebook ID.  Better yet, let them pick.  Your customers will thank you because that is one less password they have to remember.http://msdn.microsoft.com/en-us/library/bb676633.aspx
  3. Don’t let the bad guy pretend to be a legitimate user.  How do they do that?  Cross-site scripting (XSS) is the most common vulnerability I run across in the wild.  That is followed closely by cross-site request forgery (CSRF).  Both of these can be leveraged by an attacker to cause a user to shoot themselves in the foot.   This is a huge topic which probably warrants its own post.  I’ll try to break it down.
    • sanitize! sanitize! sanitize! Consider every piece of data which is ever in a user’s possession as evil. This includes cookies, form variables, url parameters, and uploaded files. They are all evil and must be stopped.  I do mean everything.  Use somebody else’s form sanitization library.  Again, they have thought of things you haven’t.  http://blogs.msdn.com/b/securitytools/archive/2010/09/30/antixss_2d00_4_2d00_0_2d00_release_2d00_notes.aspx
    • Canaries are your friend.  This is the only effective way to prevent cross-site request forgery.  Multi-step forms don’t work.  Cookies don’t work.  Use a challenge-response system with canaries to validate that a user really just came from one of your pages.
      https://www.owasp.org/index.php/Cross-Site_Request_Forgery_(CSRF)
      _Prevention_Cheat_Sheet
    • Use HTTP commands as designed.  Never change state with an HTTP GET.  Use a POST.  It may take some extra JavaScript foo, but it is much harder to attack.
    • Scan every version of your code.  There are a number of automated XSS scanners on the market.  They are pretty good at finding script kiddie vulnerabilities.  If you are a juicy enough of a target to warrant attention by ‘advanced’ researchers’, you may want to invest in a second set of eyes.  Trust me, an expert pentest crew is a whole lot cheaper than getting horribly owned.
  4. Don’t do dumb things with SQL.  It never ceases to amaze me that SQL injection still works. Use stored procedures for everything.  Also, building an SQL string in a stored procedure and EXECing it is just as bad as parameterized SQL.  Don’t do it.
  5. SSL is good.  If the data is important enough to put behind a login page, it is important enough to protect with SSL.  Period.
  6. Protect data in storage.  This is a topic I am planning on writing a dedicated post about.  The news is full of companies whose data has been stolen and put on pastebin or similar.  If it shouldn’t be shown to the world, it should be encrypted.  Stay tuned for the specifics of this.

As I write this, you may notice that none of these items are specific to the cloud.  These are all best practices for developing on the internet in general.  That is because they are the same thing.  Cloud == internet, internet == cloud.  Marketing will say what marketing will say.  For the rest of us, nothing has changed.  The web is still the web.  If you can secure one, you can secure the other.

Sinus Surgery (Days 7-10)

8 Days Post Surgery7 Days Post Surgery

I started bleeding again last night.  It was worse this time.  It went right around the packing he added after yesterday’s cauterization.  I did eventually manage to get it stopped.

I set up an appointment to go back into Dr. Dawson.  He poked around again and couldn’t figure out which area had been bleeding and couldn’t find any obvious contenders for more cauterization.

Very apologetically, he said that he would have to completely pack that side with gauze just like it was right after surgery.  He also said that this sort if thing happens very rarely.  I went home with a packed left sinus.

8 Days Post Surgery

I got almost no sleep.  My right sinus is flowing 49% of normal air.  It turns out it takes 50% in order to sleep comfortably.  It was another night of mouth breathing.

Other than that, I can say I feel great.  For a person who doesn’t have unusual bleeding problems, I can anticipate that a week after surgery they would be feeling right as rain.  Everything is still a bit swollen and tender, but I’m no longer bleeding and feel pretty much normal.

I went back to work today too.  I am a little worn down, but I’m able to get things done.

9 Days Post Surgery

Need Sleep.  My right side has completely rebelled and decided that it wants to swell closed.  4 days without sleep…  Is this what it’s like to have children?  I can’t blame it.  I’ve been trying to use it for 100& of my oxygen intake needs.  It is probably just inflamed.

I went in to Dr. Dawson’s office to have the packing removed.  It came out easily, but it was still a strange feeling.  He vacuumed out both sides again and said that everything is healing up nicely.  Some of the cauterizations are still angry.  He put some Polysporin on them and used a little dissolvable gauze for protection.  He was able to place the gauze in such a way that I can still breath around it.

10 Days Post Surgery

I slept 10 hours last night.  Both sides are wide open and happy.  No bleeding.  I feel fantastic!

< Sinus Surgery (Day 6) | Sinus Surgery (3 Weeks) >

 

Sinus Surgery (Day 6)

6 Days Post Surgery

I never did manage to get the bloody nose under control yesterday.  I would get it stopped by packing my nose with gauze, but the bleeding would start again minutes after I removed the packing.  Luckily, it was down near the tip where I could keep it under control.  Any higher up and I would have had to go into the ER or urgent care — it was the weekend.

I spent a pretty miserable night with one nostril packed.  The other side decided to go rogue and get all congested and swollen.  I didn’t get much sleep.

This morning I called Dr. Dawson’s office and was told to come in.  He poked around with his scope looking for the offending spot.  It looks like one of his incisions broke open.

He pulled out the silver nitrate sticks and got to work.  Even though he had hit the whole are with Lidocaine, it hurt like heck.  By far that has been the most painful part of the whole ordeal.  Imagine rubbing habanero peppers inside your nose.

I went home with big manly tears welling up.  On the bright side, he said that it is perfectly normal to suffer continued congestion after the surgery for 2-3 weeks.  I’m bummed it isn’t instant relief, but I’m relieved that everything is on track.

Mostly due to lack of sleep I took another day off work.  Luckily my job primarily consists of wading through emails.  That sort of thing is just as easy to do at home loaded on Vicodin. What? No. We can’t stop here. This is bat country.

< Sinus Surgery (Days 0-5) | Sinus Surgery (Days 7-10) >

Sinus Surgery (Days 0-5)

The Story So Far

I’ve always had trouble with my nose.  During my younger years you would often find me with Kleenex shoved up one or both nostrils stopping my most recent bloody nose.  As I have grown older, the nose bleeds have gotten less numerous but allergy season got worse.  I will often have complete obstruction of one side of my nose at night.  When I say complete obstruction, I mean complete.  You could one of my nostrils as a suction cup if you wanted to.

I’ve tried every nasal spray on the market: Flonase, Nasonex, Patanase, Rhinocort.  I’ve also tried all of the allergy pills and run through more Sudafed than a meth lab.  Nothing offers relief for more than a few days before it stops working.  Afrin works, but I don’t want to become an addict to the stuff.

After a discussion with my ENT and a round of CT scans, we decided surgery was the only option.  My scans showed several problems.  I have my dad’s deviated septum (he had an operation in 98).  This causes a fair bit of blockage on the right side.  My inferior turbinates are significantly oversized. My middle turbinates have concha bullosa (ie. air pockets trapped in the middle).  As if that isn’t enough, the CT scan show a chronic sinus infection in the maxillary sinuses which won’t respond to antibiotics.  This is due to undersized or closed off passages into them.

I decided it was time to go under the knife and get the works:

  • Septoplasty — removal of the deviated cartilage of my septum
  • Ablation of the inferior turbinates — using radio waves to scar the tissue of the inferior turbinates from the inside out thus preventing them from swelling
  • Resectioning of the concha bullosa in the middle turbinate — he is cutting off the “bubble” on the middle turbinates so they are smaller
  • Intranasal Ethmoidectomy with Maxillary Windows — he is increasing the size of the openings into my maxillary sinuses to improve flow and let my body kill the chronic sinus infection and relieve the pressure I feel.
  • Cauterization — he is going to cauterize a couple blood vessels where I still get bloody noses

Pre-Op

I wasn’t worried about the risks of surgery.  Honestly what really had me freaked out was the idea of general anesthesia.  I don’t like the idea of being completely out of control and unaware as people do God knows what around me.  The nurses tried to help by distracting me and asking some random questions.  They were all very nice.  I was glad that I didn’t spend much time waiting for my turn in the operating theatre.

I snorted some Afrin, filled out some paperwork, Dr. Dawson came in to ask if I had any last minute questions, then it was time to go.  The nurse lead me in and laid me down on the table.  I was doing a fair amount of freaking out when the nurse said, “here we go.”  It felt like a gentle pressure at the back of my brain and then everything went black.

Post-Op

I woke up sitting in the post-op room with an oxygen mask on my face that was gently misting me with water vapor.  My nose was packed with gauze.  The only pain I felt was a slight sting on my septum near the tip of nose.  Honestly, that’s the only pain I felt the entire time.  The nurse fed me a hyrocodone and a saltine cracker then made me drink a cup of water.  After a short amount of time they took me into the recovery room where my wife was waiting.  Dr. Dawson came by and asked how I was feeling.  He told me everything went well and I should expect a lot more air in my future.  After an hour we went home.

They left me with a little elastic band that held a piece of gauze around the tip of my nose.  It caught some leakage which was escaping the packing.  At first it needed to be changed every 15 minutes.

Emily propped me up an easy chair and fed me some soup.  I was really feeling pretty good.  It’s obnoxious to breath out of your mouth constantly, but I felt almost no pain.  I took a pain pill every 4 hours and made sure to drink lots of water.  Swallowing was tough for a little while.  It took a couple hours but I eventually figured out how to swallow with a packed nose.  It became second nature.

By dinner time I was ready to eat some real food.  Scrambled eggs were easy to eat.  I tried a piece of toast but the crumbs kept getting caught in my throat and reducing me to a fit of coughing and hacking.

By this point I was replacing the gauze under my nostrils every several hours.  I probably could have taken the mask off, but it was convenient to leave it alone.

The First Night

I didn’t sleep much the first night.  It was partially due to having to breathe out of my mouth.  It kept drying out and waking me up.  It was incredibly helpful to have some petroleum jelly handy to cover my lips which were getting dry and cracked.  It was also imperative to have a big glass of water.

The biggest obstacle to sleeping was probably having to sit upright.  I took the Doctor’s instructions to keep my head elevated a bit more literally than I probably needed to.  It was hard to get comfortable.

24 Hours Post Surgery

Dr. Dawson had me scheduled to come in the next day to get the packing removed.  Emily drove me to his office and waited why he took care of me.  To say removal of the packing was a strange experience is quite an understatement.  I could feel it moving behind my eyeballs.  It didn’t hurt.  It was just really REALLY strange.

After the packing was out, he took the same type of vacuum a dentist would use and sucked some of the clots out.  He left the septum splints in.

I could breathe out of my nose….. for about 15 minutes….. and then clots and gunk sealed me off again.  I still felt little pain and even stopped taking my pain pills during the day.  I took one before bed more to help me sleep than anything.

That night I slept like a rock.  It was the combination of being a little more comfortable and accumulated extreme exhaustion.

3 Days Post Surgery

I went back into Dr. Dawson’s office to get the splints removed.  There was a little pinch when he pulled the stiches but it was more surprising than anything.  My nose was very happy to get them out.  It had been trying to flush them out with snot for the last 48 hours.  I was really sick of being gross and snotty.

The vacuum came back out and he gave me a thorough cleaning.  Afterward I felt fantastic.  I had a little blood drip but nothing an occasional wipe with a Kleenex couldn’t keep at bay.

He told me to keep it moist with saline, and surprisingly that I could blow my nose gently.  He also said if it started bleeding hard that I should go to his office or the ER, but he didn’t anticipate that.  He also said it was all downhill from here and that I should be careful and not overexert myself as I feel better.  I was scheduled to come back in 2-3 weeks.

Strangely enough, he told me not to use a neti pot for a couple weeks.  He told me to stick with saline spray.  I wonder why that is.

That night I slept wonderfully.  Both nostrils were flowing 25% of what I would consider normal.  That was just enough to sleep.

4 Days Post Surgery

I’m getting a little bleeding down the back of my throat.  It isn’t enough to be worrisome, but enough to be obnoxious.  I’m still feeling a bit fatigued, but way better than the last few days.

5 Days Post Surgery

I’m getting a little worried because my right sinus is still congested to the tune of about 25% of normal air flow.  It will open occasionally and give me hope.  I’m afraid that it wasn’t reamed out enough and I’ll have to go back in.

I’ve searched the internet and found several posts saying that it takes a couple weeks for the turbinates to shrink after ablation.  The left side is wide open.  I’m wondering why the right isn’t.

My nose started bleeding this morning.  I was concerned until I realized it is right near the tip at a place I can pack with gauze myself.  I’ve spent most of the day with a cotton ball stuffed up there.  I spritzed the latest cotton ball with Afrin to slow the bleeding.  That’s a trick my ENT showed me when I was a kid.  It seems to have worked.

I think the bloody nose was caused by the septoplasty incision drying out and cracking.  That goes to show how important regular saline spraying is.

Other than that, I feel fantatic.  My energy level is just about back to normal.  I haven’t pushed myself, but I anticipate being able to go back to work tomorrow.

Tips for those about to undergo sinus surgery

  • Acquire one absolutely amazing wife who will be kind and gentle and take care of you at your worst.  It helps if she is really good at making comfortable nests out of pillows and blankets.
  • Have plenty of soft foods ready before you go into surgery.  You will be starving when you get home.  Soup, pudding, and scrambled eggs are good bets.
  • Have a supply of 2×2 gauze pads.  They can be used to collect leakage or rolled and moistened to clean crusted blood from your nostrils.
  • Have petroleum jelly or chapstick handy for your lips.
  • Make sure you are working to hydrate the two days before surgery.  You aren’t allowed to eat or drink the night before.  Not eating isn’t hard.  You’ll be glad you are well hydrated.
  • Take a full week off of work.  I was in no condition to leave the house for 6 days after.

Sinus Surgery (Day 6) >