Beyond the “central sinus”: radiographic findings in patients undergoing revision functional endoscopic sinus surgery

Abstract

Functional endoscopic sinus surgery (FESS) is widely used by otolaryngologists to treat chronic rhinosinusitis (CRS). The sinonasal anatomy and pathology found in patients with CRS varies widely, as does the FESS technique practiced by otolaryngologists. Variations in the completeness of cell group dissection, combined with the technical challenge of angled endoscopy, result in a wide variation of the post-FESS cavities harboring persistent disease. The purpose of this study was to identify previously incompletely dissected anatomic structures associated with mucosal thickening found in patients undergoing revision FESS for persistent or recurrent CRS. Retrospective review of axial, coronal, and sagittal computed tomography (CT) scans of patients undergoing revision FESS by 3 fellowship-trained rhinologists at a tertiary referral center. The CT scans of 55 patients undergoing revision FESS were reviewed. The most frequent radiographic findings were residual anterior and posterior ethmoid cells or septations, found in 65% of sides and 75% of patients. In addition, residual anterior ethmoid agger nasi cells, unopened sphenoid, and residual uncinates were found in 52%, 51%, and 46% of sides, respectively. A large percentage of the patients demonstrated residual ethmoid cells present on the lamina papyracea and skull base, with a lower number found posterior to the middle turbinate basal lamella. A greater number of residual right-sided vs left-sided ethmoid cells was noted, with the difference being significant (p < 0.05) at the skull base. Analysis of CT scans of patients undergoing revision FESS for persistent or recurrent CRS frequently reveals persistent anatomical structures or incompletely resected cells associated with persistent mucosal thickening. Meticulous, complete cell group dissection combined with use of angled endoscopy along with identification of possible predisposing structures may aid in the reduction of need for revision surgery.