Revision Sinus Surgery Poses Unique Challenges

In polyp patients, distorted anatomy, loss of landmarks and potential surgical disorientation are of even greater concern, as it is often in the setting of extensive disease and increased bleeding as well, Dr. Sindwani said.

Image-Guided Surgery

Revision surgery is a good reason to use an image-guided system. CT helps with preoperative planning for revision surgery. Intraoperatively, these powerful systems will localize the position of the surgeon’s instrument in relation to the patient’s sinus anatomy in a real-time fashion, and thereby improve the surgeon’s ability to stay oriented and safe, Dr. Sindwani said.

A few companies have come up with less expensive, more compact image-guidance systems that have made it possible for surgeons to perform image-guided RESS in settings outside of large hospitals and major academic centers, he said.

Image-guided technology is especially important for the frontal and sphenoid sinuses, Dr. Friedman said.

Another point about CT is that what is looked for in revision cases is different from what is looked for in primary cases, he said. The CT for revision cases is often less dramatic than in primary cases who have not had surgery to help with clearing of secretions. There is less opacity.

The revised patient may have had surgery to open a passageway, but if a new passageway was created and the natural one is still blocked, the patient may still be getting infections along with symptoms of purulent secretions.

It is key to use endoscopic findings to clarify what is happening, Dr. Friedman said.

Postoperative Care

Good postoperative care can reduce the need for RESS, Dr. Sindwani said. Seeing a patient in the office one or two weeks after surgery, once or twice, to inspect how well the sinuses are healing is good practice.

If there is evidence of early scarring or synechiae formation in critical areas, this can be dealt with in the office while the scars are still immature. You can take down some scarring in the clinic using topical anaesthesia, he said.

The middle turbinate should be watched. In cases where he has had to work on sinuses where the middle turbinate had been lateralized after previous surgery, Dr. Sindwani said he can take steps to ensure that the same thing does not happen again. This can include total or partial resection of the turbinate, the use of spacers, or using endoscopically placed sutures to hold the turbinate in place (against the septum) during the RESS in the OR.