40 Revision Sinus Surgery of the Ethmoid Sinuses

David R. Edelstein

The effective, long-term treatment of patients with chronic rhinosinusitis represents one of the greatest challenges facing otolaryngologists. With chronic sinusitis becoming the leading chronic disease in the United States today, the issues associated with treating these patients have increased.1 Each patient with chronic sinusitis poses a very challenging quality of life issue for the physician.^2,3 The improved effectiveness of diagnostic tools, such as rapid computed tomography (CT) scanning and endoscopic examination of the nose and paranasal sinuses, has led to more surgery. This rise in surgical volume, unfortunately, has also led to more failures, underscoring the need for doctors to understand both how to treat the long-term sinusitis sufferer and how to approach revision sinus surgery. The goal of any revision surgery should be to cure disease, to ameliorate symptoms, and to avoid complications.

The significant failure rate experienced after initial sinus surgery is attributable to several different factors. First, sinusitis is not a monolithic disease but five different diseases grouped under one name. There is an anatomical form, an infectious form, an immunologic form, a ciliary dyskinesia form, and a mucus disorder form. Some forms of sinusitis are more amenable to effective cure by surgery than others. For example, the anatomical form of sinusitis, where there may be a septal deflection blocking the middle meatus outflow tract, is generally very curable through nasal and sinus surgery. However, most patients suffer from more than one type of this disease, leading to mixed surgical results.

Second, the anatomy of the ethmoid sinuses makes them susceptible to initial surgical failures.⁴ Commonly called a labyrinth, the ethmoid sinuses are divided into three major sets of cells with several subsets and adjunctive cell groups. The ethmoids are made up of the infundibular cells, the bullar cells, and the posterior cells. Most ethmoid surgery involves the anterior two sets, the infundibular and the bullar cells, which drain through the middle meatus. Endoscopic sinus surgery drains these cells best through an anterior approach. A common source of surgical failure is the inability of many sinus surgeons to identify readily the middle and posterior drainage patterns through the superior meatus. The ground lamellar, which is the attachment of the middle turbinate to the lateral wall, may impede the drainage of bullar cells into the middle meatus. Thus, attention should be paid to opening the superior meatus, the “forgotten meatus.”⁵ Indeed, the sphenoethmoid recess is more important to the eventual success of severe ethmoid sinusitis cases than most surgeons realize. Although an anterior endoscopic approach to the posterior cells is possible, and makes it easy to visualize these cells postoperatively, they cannot drain unless they have easy dependent drainage, which is usually not possible to achieve through an anterior approach. Haller, Onodi, agger nasi, and sinus lateralis cells may also need to be identified preoperatively and intraoperatively to achieve full ethmoid sinus drainage.

Finally, sinus surgery itself is not uniform. There are many variations in the types of sinus surgery performed depending on the physician’s background, training, philosophy toward the use of technology, and his or her perspective on miniature openings for sinus ostia.^6,7 Depending on the approach taken in the initial procedure, the extent to which revision surgery may be required and its effectiveness can vary widely. For example, many patients who underwent sinus procedures before the advent of endoscopic sinus surgery had traditional inferior meatal openings, with the more natural middle meatal ostia being left untouched and blocked. Patients who underwent such Caldwell-Luc procedures without opening the middle meatus may now present with abnormal ciliary linings of the maxillary sinus due to the complete stripping of the natural respiratory mucosa, which was a common result of the older forms of maxillary surgery. Other patients may have had destructive middle turbinectomies as part of older intranasal sphenoethmoidectomies, which will reduce the effectiveness of the newer endoscopic approaches and thus limit long-term results. Some of these patients may have formed scarring or synechiae in the sinus outflow tracts, requiring wide débridements.

Those patients who had only limited first-time surgery may need completion surgery. For example, some sinus surgeons choose to operate on only one side at a time, creating a need for revision surgery on the unoperated side. Other surgeons may have been loath to enter the frontal or sphenoid sinuses, leading to problems later on in the downstream ethmoid and maxillary sinuses. Finally, some surgeons never enter the more dangerous posterior ethmoid sinuses on the first surgery, hoping that the posterior cells will recover when the anterior ones clear. This variation in surgical approach makes evaluating the literature on failure rates somewhat difficult, given the need to understand authors’ experiences, philosophies, and approaches to first-time cases.

Decision tree for chronic rhinosinusitis surgical failure

Evaluation for Revision Cases

It is very important to review the records, including previous operative reports, of any other surgeon who has operated on the patient to have a road map of the success or failure of previous treatments. Before planning revision surgery, the conditions of areas such as the septum, middle turbinates, sinus meati, and special ethmoid cells should be carefully evaluated. Any complications to the fovea ethmoidalis or lamina papyracea as well as bleeding should be highlighted and identified. The patency of the sphenoid ostia and the frontal duct also should be investigated in the operative reports.8 Unfortunately, operative dictations are not always complete or mention all areas of interest. Many surgeons, for example, do not note thinning of the lamina or report every breach of the orbit, even though they should.

Young sinus surgeons should be trained to spend time on their dictations and to develop a consistent style of reporting indications, findings, and surgical approaches accurately. Even if an area is not touched, for example, it should be mentioned in the operative report both to help with postoperative care and to record the fact that the surgeon thought about the possibility of unrecognized disease in that area. Every residency training program should periodically read, review, and grade the accuracy and reliability of surgical dictations to instill an understanding of the important role that accurate documentation plays in patient care (and surgical billing).

CT and MRI Evaluation

A fine-cut CT scan with 1 mm cuts is an essential element in the work-up of sinus surgical failures. The surgeon should ask for axial, coronal, and sagittal views, if available. Axial views provide an anteroposterior dimension. They can help the surgeon find the lateral wall of the posteriormost ethmoid cells and the sphenoid cells by helping to determine whether the lamina papyracea is flat or triangular in relationship to the orbital apex.⁹ Coronal views help illuminate the ostiomeatal complex and the differences between the two sides. A coronal view can also help to identify higher cells on one side that may have been unopened during the first sinus surgery. This view will be essential if the frontoethmoid recess is to be opened at the time of revision surgery. Both axial and coronal views may help to identify areas of possible osteitis, particularly of the sphenoid sinus and orbital apex. Patients with suspected osteitis should be treated with either a course of long-term quinolone antibiotics or intravenous (IV) antibiotics prior to surgery.¹⁰

The sagittal view is underappreciated for its ability to help identify the drainage patterns of the posterior sinuses. In particular, sagittal views can aid the surgeon in determining the position of the ground lamella, which gives the insertion of the middle turbinate into the lateral wall. The superior meatus may lie anterior to the ground lamella or above it. Polyps growing from the posterior ethmoid sinuses may be appreciated blocking the superior meatus and only be identifiable on the sagittal views. To avoid complications of surgery in scarred bullar cells, it is essential to determine the position of the base of the skull and the down sloping of the middle ethmoid cells. Sagittal views also help to orient the revision sinus surgeon as to the dangerous angles and location of any infected cells at the base of the skull.

Comparing a current CT scan with a CT scan taken before the first surgery can also be helpful if the original preoperative scan is available. Such a comparison may help to differentiate between retained cells, scarring from the first surgery, and problem areas. A comparison of the two CT scans, for instance, can identify new areas of infection and areas of sinusitis inadvertently caused by the first surgery. It is essential to identify these areas to avoid making the same mistakes twice. Additionally, this comparison may highlight small but important deflections of the septum and floppy middle turbinates.

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