Decision making in revision sinus surgery

Abstract

Success in endoscopic sinus surgery (ESS) occurs in 85 to 95% of patients. Approximately 5 to 15% of patients fail and require revision sinus surgery. Some of the same problems that cause failure for primary ESS could also be a problem for revision surgery. Nasal polyps, extensive disease, and previous surgery are problematic cases. Underlying problems such as cilial abnormalities, immunodeficiency, and cystic fibrosis need to be taken into consideration in surgical planning. The most common symptoms noted in the patient with failure are headache and symptoms of recurrent infection. The most common anatomic problems related to failed surgery are a retained or intact uncinate process and a lateralized or destabilized middle turbinate. Pathophysiology noted on objective evaluation includes anterior and posterior ethmoid disease; frontal recess obstruction or stenosis; an obstructed, blocked, or closed antrostomy; recirculation phenomenon; recurrent or persistent fungal disease; and sphenoid obstruction or closure. Surgical decision making designed to treat these problems is carefully planned and targeted with surgical alternatives ready as back-up. Stereotaxic computerized ESS is very helpful in finding disease and identifying the orbit and skull base. These points of interest are reviewed in an effort to give an overview of what is required for appropriate decision making in ESS.