What causes chronic nasal congestion which responds to afrin but not astelin, flonase, or sinus rinses? Can surgery even work in a case like this?

Afrin (oxymetazoline) rebound. Afrin (oxymetazoline) causes severe narrowing of the blood vessels in the nose and thus the effect on decongestion. However prolonged constriction leads to decrease blood supply to the tissue and may lead to permanent damages. The nose also becomes less responsive to afrin (oxymetazoline) with prolonged use . Flonase counteracts inflammation and Astelin is an antihistamine and neither constricts the blood vessels.