Revision Endoscopic Sinus Surgery
Since the development of endonasal endoscopic sinus surgery, many studies have attested to its therapeutic effectiveness [5 ,6 ,8 ,15 ,17 ,22 ]. Nevertheless, for some patients, endoscopic surgery fails to relieve persistent or recurrent sinus disease. Th
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Revision Endoscopic Sinus Surgery JEAN-MICHEL KLOSSEK
Introduction
First Step: Study of the Past Medical Story
Since the development of endonasal endoscopic sinus surgery, many studies have attested to its therapeutic effectiveness [5,6,8,15,17,22]. Nevertheless, for some patients, endoscopic surgery fails to relieve persistent or recurrent sinus disease. This subset of patients may require revision surgery. The management of patients previously operated on with an endonasal or external approach remains a challenge for the surgeon, and some guidelines (Table 29.1) are helpful before deciding to perform revision surgery [1,7,12]: • Past medical history • Type of previous surgery • Preoperative management • Technical approach
Although the results of previous studies are difficult to analyze (because of a lack of standardization of the pathologies included [14]), inconsistent medical treatment and misdiagnosis are suggested as explanations for some failures. Before deciding on a new procedure, meticulous nasal endoscopy and analysis of the patient's complaints are required to avoid a second failure. Analysis of the literature leads to the conclusion that results also depend on the pathology involving the sinuses. For example, failure of surgery in cases of mucoceles or a fungus ball is extremely rare compared with the results in cases of polyposis [9-11]. Two mechanisms may be suggested to explain a failure: technical considerations and recurrence or persistence of the pathology. Postoperative compliance of the patient must also be evaluated, because inadequate follow-up has been given as a reason for surgical failure [6].
Table 29.1. Non-exhaustive features to control in case of a revision procedure Before the procedure Type of pathology involving the sinus cavities Type of previous surgery: endonasal, external, combined Preoperative radiologicaJ exploration: CT scans, MRI Anatomic variations: thickness of the skull base and the medial orbital wall, bone defects, position of the internal carotid artery and optic nerve Preparation of the mucosa During the procedure Presence of the middle turbinate Presence of adhesions Access to the choana and the sphenoethmoidal recess Access to the maxillary sinus Presence of the uncinate process, the bulla ethmoidalis and the basal lamella of the middle turbinate Frontal irrigation At the end of the procedure Prevention of adhesions and stenosis
Second Step: What was the Previous Procedure? Nasal endoscopy is the key to analysis of the results of the previous procedure(s). Any scarring of the middle meatus, medialization of the middle turbinate or persistence of diseased mucosa is noted. The middle meatus is inspected to try to identify any remaining anatomic landmarks, such as the uncinate process, bulla or the middle turbinate. The presence and patency of a middle antrostomy or a sphenoidotomy are also noted. Edema, polyps and secretions are located. At the completion of nasal endoscopy, anatomic variations and potentially difficult areas are reviewed and explained to the p
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