Refractory chronic rhinosinusitis can be challenging to treat. Initial treatment focuses on medical and nonsurgical treatments. If these treatments fail, revision endoscopic sinus surgery is an option. A plan for revision surgery must address anatomic factors contributing to recurrence. Preoperative imaging and sinonasal endoscopy are systematically reviewed; areas of disease and “danger” zones are identified. Traditional anatomic landmarks are often obscured or absent; thus, a set of consistent landmarks (unchanged despite prior surgery) are used to navigate the revision endoscopic sinus surgery. Wide sinusotomies permit visualization and access to disease intraoperatively. Large sinus openings also facilitate post-operative debridements in clinic, endoscopic disease monitoring, and topical sinus therapy.
Key points
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The causes of primary functional endoscopic sinus surgery (FESS) failure are usually multifactorial; all aspects of anatomic, patient disease, and postoperative care should be considered.
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Revision FESS requires a clear understanding of the anatomic sites contributing to recurrence. Systematic assessment is essential.
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Traditional anatomic landmarks are distorted or absent during revision FESS. Alternative anatomic landmarks, which are consistently present despite prior surgery, are used to maintain clear surgical orientation.
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Revision FESS must address all the anatomic sites that contribute to recurrence. Wide antrostomies permit intraoperative access to disease and facilitates postoperative care.
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Revision FESS is a viable treatment option for patients who fail primary FESS and maximal medical treatment for recurrent chronic rhinosinusitis and have possible outflow tract obstruction.
Introduction
In the mid 1980s, otolaryngologists began using functional endoscopic sinus surgery (FESS) to address refractory chronic rhinosinusitis (CRS) that failed to respond to medical treatment. FESS can provide short- and long-term improvement in disease symptoms and quality of life. Approximately 250,000 patients undergo endoscopic sinus surgery in the United States alone with general good success rates ranging from 67% to 98%. However, approximately 10% to 15% of patients who have sinus surgery will undergo revision surgery. Multiple factors contribute to the need for revision surgery, including surgical technique, extent of disease, anatomic obstruction, and postoperative care. The need for revision can be of particular concern in patients with CRS with nasal polyps who have been shown to have a high rate of regrowth. This article reviews the main causes of primary FESS failure and discusses an approach to the medical and surgical treatment of recalcitrant CRS.
Introduction
In the mid 1980s, otolaryngologists began using functional endoscopic sinus surgery (FESS) to address refractory chronic rhinosinusitis (CRS) that failed to respond to medical treatment. FESS can provide short- and long-term improvement in disease symptoms and quality of life. Approximately 250,000 patients undergo endoscopic sinus surgery in the United States alone with general good success rates ranging from 67% to 98%. However, approximately 10% to 15% of patients who have sinus surgery will undergo revision surgery. Multiple factors contribute to the need for revision surgery, including surgical technique, extent of disease, anatomic obstruction, and postoperative care. The need for revision can be of particular concern in patients with CRS with nasal polyps who have been shown to have a high rate of regrowth. This article reviews the main causes of primary FESS failure and discusses an approach to the medical and surgical treatment of recalcitrant CRS.
Reasons for failure of primary functional endoscopic sinus surgery
When assessing patients who failed primary FESS, it is vital to determine the underlying cause(s) of persistent disease. Frequently, the cause is multifactorial and thus all contributing factors should be evaluated and addressed.
Anatomic, Mucosal, and Bony Factors
A number of studies evaluated the etiology of primary FESS failure and among the following causes anatomic factors are particularly common ( Box 1 ). Middle turbinate lateralization is cited as a common anatomic finding in 30% to 78% in those who fail FESS.
Frontal sinus outflow stenosis
Incomplete anterior ethmoidectomy/agger nasi retention
Incomplete posterior ethmoidectomy
Middle turbinate lateralization
Retained uncinate
Missed ostium
Middle meatus stenosis
Maxillary recirculation
Sphenoid ostium stenosis
Synechia (in any sinus)
Neo-osteogenesis
Recurrent mucosal disease
Incomplete surgery
Multiple studies report incomplete surgical technique contributing to recurrent disease ( Fig. 1 ): incomplete anterior or posterior ethmoidectomy in 31% to 74%, incomplete uncinectomy in 37%, and retained agger nasi cell in 13% to 49% Additional findings included retained intersinus septations or intrasinus cells including frontal cells and Haller (infraorbital) cells. These cells block the natural drainage pathways of the frontal, ethmoid, and even the sphenoid sinuses. Other issues include failure to locate and open the diseased sphenoid sinus, which can be mistaken for an Onodi (suprasphenoidal) cell.
Ostium stenosis, scaring, and synechiae
Stenosis occurs when circular openings contract, preventing drainage. This can be exacerbated by the buildup of scar tissue in or near these openings, creating a thick band of tissue that obstructs the sinus and fails to respond to topical treatments. Scarring and stenosis of the maxillary ostium ( Fig. 2 ) can be a common finding in revision FESS, reported in 27% to 39% of cases. Similarly, 12% to 50% of revision FESS frontal outflow tracts had scaring and/or stenosis. Although scaring and stenosis seemed to be less of an issue for the sphenoid sinus at 7%, this area is not as well-described.
Recirculation
A condition of sinus drainage obstruction where mucus is transferred out of the natural ostium, but reenters the sinus via the unconnected surgical sinusotomy. Parsons and colleagues in 1996 described in detail how failure to identify and connect the natural maxillary ostium to the surgical maxillary sinusotomy results in continued obstruction. Recirculation was documented in 4% to 15% of the subjects in several series of revision FESS subjects.
Neo-osteogenesis
This is a feature of unclear etiology described in CRS and more frequently in recurrent CRS. It may be associated with the degree of tissue eosinophilia and was found in 36% to 53% of patients with CRS (using radiographic and pathologic criteria). Neo-osteogenesis was thought to be a main finding contributing to recurrent CRS in multiple sinuses ( Fig. 3 ).
Recurrent mucosal disease
Return of mucosal thickening, and particularly polyps, was documented in many studies as a main factor in ostium obstruction in recalcitrant CRS ( Fig. 4 ).
Patient Disease
Patients with recalcitrant CRS disease and persistent symptoms after primary surgery often have recurrent mucosal disease that can be partly triggered by their underlying disease etiology. Although surgery reduces the disease burden, it often does not address the underlying etiology of disease. Studies document that patients with CRS and nasal polyps tend to have higher rates of recurrent disease. In these patients, the approach to primary surgery technique (removal of the middle turbinate, wide osteotomies, etc) and postoperative management with frequent debridements, topical and oral medical therapy, and monitoring, are critical to minimize the propensity for recurrence. However, there are particular subsets of CRS patients for whom it is of paramount importance to consider the underlying etiology and pattern of disease, so that patients receive appropriate treatment to reduce recurrence.
Allergic fungal sinusitis
Bent and Kuhn developed 5 main diagnostic criteria for allergic fungal sinusitis: allergy to fungi, positive fungal stain of the sinus contents, nasal polyposis, characteristic findings on radiography, and production of eosinophilic mucin. The pathophysiology is not clearly understood, but is likely related to type 1 hypersensitivity to fungal antigens. The characteristic thick obstructive mucin is not easily cleared, reduces sinus aeration, and can promote a fertile environment for inflammation and bacterial overgrowth. Surgery is the mainstay of treatment with wide sinusotomies facilitating postoperative debridements and topical therapy. However, there is an high rate of recurrent disease. Thus, in addition to surgery, aggressive medical treatment with systemic and topical nasal steroids are necessary.
In the initial postoperative period, the senior author combines monthly postoperative nasal endoscopies with or without debridements (after the initial postoperative visit at 7–10 days), along with nasal saline rinses, topical nasal steroids, and culture-directed topical and oral antibiotics. Cultures are collected intraoperatively. In patients who have remaining postoperative polypoid tissue, an oral steroid burst with 1 week of each 40 mg/d followed by 20 mg/d, is given with culture-directed oral antibiotics. Subsequent bacterial infections are treated with a steroid burst and culture-directed topical and oral antibiotics. Additionally, patients are evaluated and treated for significant environmental allergies.
Impaired secretion clearance
Patients with impaired ciliary clearance (ciliopathies: primary ciliary dyskinesia, Kartagener syndrome, etc ) or mucosal stasis (cystic fibrosis ) are prone to recurrent obstruction, infection, and mucosal inflammation after surgery. These patients require frequent debridements and wider sinusotomies, to permit in-office debridement and removal of secretions that the patient cannot clear by rinsing alone.
Biofilms
A biofilm is an organized matrix of bacterial microcolonies that can share plasmids, promoting antibiotic resistance, and permitting greater adhesion of the organisms to the mucosal surface. Biofilms reduce susceptibility to antibiotics and lead to poorer quality of life, with more frequent postoperative infections. Prince and colleagues showed that patients who had prior sinus surgeries had a higher prevalence of biofilm-forming bacteria. The severity of disease and pattern of postoperative response may vary with the species of biofilm forming bacteria; Staphylococcus aureus is associated with worse postoperative disease. There is a significant amount of research into biofilm eradication strategies. Foreman and colleagues divided these strategies into 3 categories: topical antibiotics such as mupirocin and tobramycin; biofilm dispersal, including surfactant and enzymes; and physical removal with hydrodebridment.
Immune deficiencies
Patients with recurrent CRS seem to have an increased prevalence of immunoglobulin deficiencies, reported at 4% to 22%. A metaanalysis by Schwitzguebel and colleagues found the pooled prevalence of immunoglobulin (Ig)G, IgA, and IgM deficiencies was 13% in recurrent CRS patients. These patients require specific treatment to address their underlying immune system deficits. The senior author routinely orders a basic immune work-up including immunoglobulin levels (with IgG subtypes) in patients who present with a history of recurrent sinusitis and severe recurrent upper airway infections unresponsive to antibiotics or with symptoms out of proportion to endoscopic or radiographic findings.
Aspirin-exacerbated respiratory disease
Often presenting as Samter’s triad with aspirin sensitivity, asthma, and nasal polyposis, attributed to manifestations of abnormal arachidonic acid metabolism. The inhibition of cyclooxygenase exacerbates the production of leukotrienes and mast cell degranulation. The nasal polyps in these patients are often less responsive to standard medical or surgical treatment. Mendelsohn and colleagues found patients with Samter’s triad were 2.7 times more likely to have recurrent disease and revision surgery than CRS patients. Multiple studies found a significant decrease in the number of revision sinus surgeries after aspirin desensitization therapy.
Postoperative Care
There are no standardized protocols for postoperative care. Postoperatively, there is a propensity for sinonasal buildup of old blood, purulence, mucous, and/or unabsorbed packing, which form hard crusts on raw mucosal surfaces. This results in nasal obstruction, retained secretions, and reduced sinus aeration. The environment can lead to increased inflammation and scarring, and create a fertile breeding ground for bacteria.
Medical treatment
Nasal saline irrigations help to flush out and remove the postoperative buildup of loose crusts, while moisturizing the nasal airway. Several high-level studies found postoperative nasal saline rinses improve postoperative symptoms and endoscopic appearance.
Topical antibiotics are useful in CRS by reducing the need for repeat surgery, and improving postoperative symptoms and endoscopic findings. The literature on the use of postoperative oral antibiotics is mixed. Evidence does not support using short courses of antibiotic postoperatively, but some studies show that a longer course of antibiotics can improve endoscopic scores and crusting. None of the studies used culture-directed antibiotics. The senior author routinely collects cultures (tissue or purulence) intraoperatively and places patients on 4 weeks of culture–directed oral and topical antibiotics postoperatively. No antibiotics are given before surgery to ensure representative culture data.
Topical steroids are useful for long-term maintenance and control of mucosal inflammation, particularly in patients with polyps. Cochrane reviews found that topical steroids improved symptom scores and had a greater proportion of responders in both polyp and nonpolyp CRS patients. Subgroup analysis indicated that sinus delivery methods (saline rinses) tended to be more successful than nasal delivery (nasal spray) methods in patients who underwent sinus surgery. The senior author routinely places patients on postoperative long-term topical nasal steroids. Several nasal steroid sprays are currently available without a prescription and are traditionally well-tolerated and affordable, and have minimal side effects. In select refractory polyp cases, topical budesonide is a helpful adjunct.
Endoscopic debridements
Debridement improves postoperative endoscopic appearance and symptoms, and reduces the risk of synechiae development or middle turbinate lateralization. The procedure involves removing sinonasal debris in the office, using a rigid endoscope and a variety of instruments, such as assorted suctions and forceps. The timing and the frequency of debridements varies widely, although it is generally accepted that debridements are necessary for 1 to 2 months postoperatively. The senior author performs debridements at 1 and 4 weeks postoperatively, and if necessary, monthly thereafter until the mucosal membranes start to normalize. Once patients improve, nasal endoscopies are spaced to 3 to 6 months for the first year, or more frequently if the patient experiences worsening symptoms. In these visits, meticulous removal of crusts, retained secretions, granulation tissue, and devitalized bone are performed. Scarring and synechiae are lysed with a through-cut forceps or endoscopic scissors. Developing infections or early recurrence of polypoid tissue are treated aggressively with culture-directed antibiotics, and oral and/or topical steroids. In-office polyp removal (using a microdebrider) is performed if polyps obstruct a major sinus outflow tract.
Allergy assessment and treatment
The exact role of allergy in CRS has not been determined fully. Even the association of allergy with CRS has conflicting reports in the literature. There is some evidence to suggest that allergy may predispose patients to the development of CRS. Tan and colleagues suggest that allergy may play a role in the development of an impaired epithelial barrier and thus acts as a modifier of sinusitis. The senior author routinely refers patients with characteristic symptoms or recalcitrant disease for allergy evaluation and treatment.
Treatment of recalcitrant sinusitis
Recurrent sinusitis is extremely challenging to treat. It is essential to reevaluate prior workups and treatments, and systematically approach additional treatment. Interventions should emphasize treating the patient and not the imaging studies. In particular, the focus is on maximizing quality-of-life outcomes.
Maximize Medical and Nonsurgical Treatments
Many patients who develop recurrent disease after primary surgical treatment respond to appropriate medical therapy, including a steroid burst for 2 to 3 weeks, and culture-directed antibiotics. In addition, it is important to review the role of maintenance treatment, with at least twice daily nasal saline rinses and topical steroids. Patient compliance is a critical factor influencing outcomes. Frequently, patients who have initial postoperative success will reduce or cease the use of maintenance treatments. The role of patient education about the chronicity of their disease, appropriate self-management, and maintenance treatments should not be forgotten.
Prior preoperative history, workup, and postoperative course are reviewed in detail to help the rhinologist identify gaps and assess for untreated underlying patient disease. Strong consideration is given to the patient disease states mentioned elsewhere in this article, as well as environmental changes, new exposures, and autoimmune disorders. If allergy assessment was not performed, this is completed before considering surgical intervention. Additional treatment options include immune modulators such as interleukin-5 inhibitors, leukotriene antagonists, immunosuppressants such as methotrexate, and monoclonal anti-IgE therapy. Collaboration with allergists, immunologists, pulmonologists, and infectious disease specialists may be necessary in particularly challenging patients.
In select patients with isolated polyp disease, in-office polypectomy can be considered, provided the patient does not have significant comorbidities or anticoagulant medications. The senior author performs these procedures using a microdebrider with topical anesthesia. Steroid-eluting stents are a relatively new option for patients with recurrent ethmoid polyposis, and small studies indicate improvement in short-term patient outcomes and polyp grade.
Principles of Revision Surgery
In revision surgery, it is essential to develop a clear picture of the anatomic sites contributing to recurrence to create a well-defined plan for surgery. This begins with a thorough in-office endoscopic examination looking at the sites of disease, assessing the state of the mucosa, and documenting scarring and landmark distortion. A detailed thin-cut sinus computed tomography scan is performed with axial, coronal, and sagittal views, to allow a triplanar assessment of the postsurgical sinonasal cavities. A detailed evaluation includes at least the elements covered in Box 2 . These items permit a thorough evaluation of the “danger” areas and set appropriate expectations for surgical intervention.
Presence of each sinus with attention to frontal and sphenoid asymmetries
Septum position and perforations
Frontal sinus and frontal recess anatomy (agger, frontal cells)
Supraorbital ethmoid cells
Anterior ethmoid artery location
Location of inferior turbinate in relation to orbital floor
Presence of the middle turbinate
Location of uncinate attachment superiorly
Skull base slope anterior to posterior and Keros classification
Dehiscences of bone around skull base, orbit, carotid, optic nerve
Sphenoid intersinus septum relationship to the carotid
Onodi (suprasphenoidal) cells
Haller (infraorbital) cells
Detailed preoperative counseling sets realistic expectations for patient outcomes. The surgeon reviews the areas of disease, the plan to address these areas, and how this surgery will be performed differently than the prior surgery. Although recent studies do not indicate differences in complication rate between primary and revision surgery, the more complex nature of the surgery and the risks are covered in detail. The postoperative care plan is laid out in advance to permit the patient to ask questions and clarify expectations.
Patients are assessed for comorbidities that require preoperative optimization and clearance and counseled to avoid all nonessential anticoagulants (prescription, over the counter, and natural substances). Consideration is given to preoperative steroids in severe polyp cases to minimize inflammation and decrease intraoperative blood loss.
Particular attention is paid to comorbidities that can be associated with higher rates of recurrence or worse outcomes. Smith and colleagues found that aspirin sensitivity was predictive of poorer endoscopic and quality-of-life outcomes. Depression was predictive of poorer quality-of-life outcomes as well.
Landmarks and Surgical Approach
In revision surgery, the standard anatomic landmarks are often distorted or absent. To ensure clear orientation, consistent landmarks are used to navigate. This section presents a stepwise approach to landmark identification and revision sinus surgery used by the senior author ( Box 3 ); this is described in similar fashion in several publications.
