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Initial endoscopic sinus surgery results have proven to be successful in 75 to 95% of cases. However, the definition of success varies from surgeon to surgeon. In most studies, it is defined appropriately as the resolution or improvement of symptoms. However, Kennedy1 has shown that symptoms do not correlate well with resolution of disease; therefore, one must evaluate the patient with the objective results taken in light of subjective complaints. Not all failures need nor undergo revision surgery. Revision surgery occurs in 5 to 15% of patients, with success rates of 63% or better.

Evaluation of postoperative failure should involve a multidisciplinary approach. Obviously, a history and physical examination are paramount. To understand decision making in revision sinus surgery, it is necessary to know why we have failed and what has occurred to make the patient again symptomatic. Several studies over the years have discussed symptoms requiring revision surgery. Usually the most common symptoms are recurrent infection and/or headache. A detailed history is important to help sort out this common complaint. Objective evaluation with endoscopic exam and CT scanning will help determine which sinuses are problematic. Seeing the patient when the patient is sick can help further focus attention to troubled sinus problems. Some underlying problems play such an important role that nothing further surgically can be done, and only symptomatic treatment is warranted.

When looking at failures, several causes have to be analyzed prior to any treatment planning (refer to Table 14–1 in Chapter 14). The patient may have the wrong diagnosis. For instance, surgery may have been performed for a diagnosis of headache. When the surgery fails to cure the symptoms even though objectively everything looks great, other causes for the headaches may become apparent. The patient may have an underlying problem that is mucosal and goes beyond infection or surgery. Suggested poor prognostic indicators include allergy, asthma, aspirin triad, esophageal reflux, immunodeficiency, cystic fibrosis, cilial disturbances, and postoperative smoking. All may cause persistent symptoms despite good objective results. Inappropriate or inadequate surgery may have been performed where too much or too little has been removed, allowing for nonphysiologically working sinus passages or persistence of disease. Poor technique may have been used, causing synechiae, turbinate instability or lateralization, and/or persistence of sinus anatomy and disease, which should have been removed. Poor postoperative observation and care may have occurred, allowing for middle turbinate or middle turbinate remnant lateralization, scarring, adhesion, synechia, or persistent disease. In some instances preserved uncinate processes, lateralized turbinate, and an uncorrected septal deviation may contribute to disease. Nasal polyps, especially with asthma and/or aspirin sensitivity, recur with the reappearance of symptoms in a high percentage of patients. Patients with extensive disease, especially with allergic fungal sinusitis or a history of previous surgery, have a high rate of recurrent disease despite the most aggressive of surgeries.2 This is probably due to the marked changes in mucosa, cilia, and, overall, surgery.

Specific anatomical areas where failure most commonly occurs are noted (refer to Table 14–2 in Chapter 14). These areas are retained uncinate process, lateralized middle turbinate, blocked or missed natural ostia, blocked frontal recess, and blocked sphenoid. Chu et al³ noted four sites of disease in at least one-quarter of patients. Ramadan⁴ looked at cases of failed ESS in 52 out of 398 total surgery patients (13%). He found that 31% had residual ethmoid air cells, 28% had maxillary ostia stenosis, 26% had frontal recess stenosis, and 15% had recirculation or missed ostia. Twenty-nine out of 56 patients (52%) had adhesions with a lateralized middle turbinate. Moses et al⁵ reported a 67% success rate of revision ESS in 90 patients out of 753 consecutive functional ESS (FESS) cases (12%). Extent of disease, nasal polyps, allergy, previous traditional surgery, male gender, chronic steroid use, and deviated septum all appeared to adversely affect outcome, which differs from the data from Marks and Shamsa.²

Symptoms that occur heralding recurrent or persistent disease include headache, purulent drainage, congestion, cough, bad breath, loss of smell, and “bad” smell. Symptoms in isolation to be wary of include postnasal drainage, which may be related to esophageal reflux, and nasal obstruction, which may be due to turbinate, septum, and/or nasal valve problems. Revision sinus surgery in these patients will not be successful (refer to Table 14–3 in Chapter 14).³

The patient with chronic sinusitis or recurrent infection after initial surgery is treated aggressively with prolonged broad-spectrum antibiotics as well as oral, topical, and sometimes injected steroids. Limited office procedures, including lysis of synechiae, correction of recirculation, limited local polypectomy, and polyp injection, may be combined with the initial aggressive medical management. On completion of this initial trial, if the patient is without relief, a CT scan is obtained to identify the source of infection. If the patient presented without indication of active disease but has chronic or recurrent complaints, obtain a coronal CT scan of the sinuses. Sometimes 1 mm coronal and axial CT scans can uncover small areas of obstruction. A reconstructed sagittal CT scan can be helpful in sorting out problems in the frontal recess. Patients with a relatively good objective examination can have hidden areas of disease, such as frontal or sphenoid sinusitis, which otherwise are overlooked unless careful CT evaluation is performed. However, patients also can have CT scans that appear relatively normal, especially if the scans are done after recent treatment with medication, so it may be important to see the patient when symptomatic. This strategy serves two purposes. First, it allows soft tissue and bone evaluation in regions that clinically appear obstructed or perhaps disease free. One should look for normal variants compromising drainage, including concha bullosa, sphenoethmoid cells (Onodi cells), agger nasi, and infraorbital (Haller’s) cells, or the persistence of infection. A retained uncinate with missed natural ostia may be more apparent on CT than clinical examination (Fig. 17–1). Second, this strategy offers a road map in a previously operated field. One should specially evaluate the lamina papyracea, the region of the cribriform plate, and the fovea ethmoidalis for dehiscence, as well as the proximity of the neurovascular anatomy of the sphenoid sinus.

Anatomy is the cornerstone of surgery. Without adequate knowledge of normal and the many variations of normal, primary FESS is high-risk surgery and revision surgery more so. To decrease the risk of complication and improve results in revision surgery, a working knowledge of fundamental anatomy is necessary. In many revision cases, patients have marked alterations in the integrity of the lateral nasal wall or severe polyposis, making it exceedingly difficult to determine where to begin safely. The first surgical step of the procedure should therefore be a complete reassessment of the lateral wall to identify any remaining landmarks.

May et al6 describe six friendly landmarks in revision FESS that offer the surgeon the ability to sort out confusing anatomy (refer to Table 14–4 in Chapter 14). The anterior arch is formed by the remnant of the middle turbinate medially, the anterior ethmoids and agger nasi cells superiorly and anterolaterally, and the lamina papyracea laterally. It protects the surgeon from staying medially in the cribriform plate. Identifying the anterosuperior attachment of the middle turbinate during revision endoscopic sinus surgery is helpful in maintaining orientation because this attachment marks the boundary between the ethmoid complex and the space between the middle turbinate and the septum. The latter space should not be manipulated because of its proximity to the floor of the cribriform plate, which is vulnerable to penetration at this point. The lamina papyracea, when previously seen on CT, guides the surgeon along the most lateral portion of the dissection, protecting the eye from inadvertent injury. The lamina is identified by finding the maxillary antrostomy immediately. The maxillary antrostomy should include the natural ostium to avoid failure. The lamina papyracea lies just lateral and superior to the maxillary antrostomy. Looking superior into the maxillary antrostomy, the floor of the orbit can be seen and followed medially to join with the lamina papyracea. The ridge formed by the border between the superior aspect of the maxillary antrostomy and the inferior edge of the lamina papyracea represents the level of the orbital floor. The posterior ethmoid is located above this ridge, and the sphenoid sinus lies below it. If the lamina papyracea and maxillary sinus floors are traced posteriorly, the ridge will define the air cells superior to it as the posterior ethmoids and inferior to it as the sphenoid sinus. For pure orientation, the sphenoid sinus will be in a plane perpendicular to a line parallel to the maxillary antrostomy. Because the location of the antrostomy is important to finding the lamina, so too is the sphenoid sinus in establishing the skull base. It is always best to find the sphenoid by locating the natural ostia if it can be visualized or is not scarred over. The sphenoid location is most commonly isolated by going superiorly 1 to 1.5 cm to the top of the choanal arch

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