Revision endoscopic sinus surgery.

Abstract

Patients with recurrent chronic sinusitis after prior surgical intervention pose a particular challenge to the otorhinolaryngologist. Establishing a correct diagnosis is the first step and requires review of the original presurgical symptoms and imaging; review of the more recent symptoms and images;and reevaluation of environmental, general, and local host factors that may contribute to persistent disease. Although primary chronic rhinosinusitis is typically a medical disease, postsurgical persistent disease may result directly from iatrogenic causes, requiring early surgical revision. Even in this setting, however, proper preoperative medical therapy is essential. Diagnostic evaluation should include meticulous endoscopic evaluation and appropriate radiologic studies. CT typically is required in the coronal and axial planes and ideally is performed using a computer-assisted surgical navigation protocol and with reconstructions in the sagittal plane, allowing for "scrolling" through the altered anatomy and conceptualizing the surgical issues at hand. When the decision to undergo revision surgery is made, the patient and the physician need to comprehend the rigorous and prolonged schedule of postoperative care and débridements that may be required for long-term success. Appropriate surgical technique emphasizing mucosal preservation and complete dissection must be adhered to. The surgeon must be aware that bony thickening is likely to be present and to make the dissection significantly more difficult than in the primary case. Medical management and endoscopic surveillance postoperatively is continued until a stable cavity is achieved.