Operative Techniques in Otolaryngology (2006) 17, 6-12

Principles of revision functional endoscopic sinus surgery

Michael J. Sillers, MD, FACS,a Kristopher F. Lay, MDb

From the aAlabama Nasal and Sinus Center, Birmingham, Alabama; and the
b
University of Alabama–Birmingham, Birmingham, Alabama.

KEYWORDS Chronic rhinosinusitis is one of the most common diagnoses in the United States and accounts for
Endoscopic sinus millions of dollars in health care expenditure every year. Most patients are successfully treated with
surgery; medical therapy, but many require primary functional endoscopic sinus surgery (FESS) to complete
Sinusitis; their treatment. Approximately 10-15% of patients who undergo primary FESS will require revision
Revision FESS. Revision FESS has unique challenges because of the alteration of anatomical landmarks and the
complexity of the underlying disease process. Successful revision FESS depends on appropriate patient
and surgeon expectations, comprehensive medical therapy, complete and appropriate preoperative
evaluation, and careful surgical technique and postoperative follow-up.
© 2006 Elsevier Inc. All rights reserved.

Since its introduction to the United States in 1985, func-
tional endoscopic sinus surgery (FESS) has revolutionized
the way otolaryngologists treat refractory paranasal sinus
disease. There are an estimated 250,000-300,000 FESS
cases performed each year in the United States. The re-
ported “success” rates for endoscopic sinus surgery range
from 67-98%.1-6 However, despite initial success, approxi-
mately 10-15% of patients who undergo surgery will require
revision surgery.5,7,8 Most patients who have primary FESS
failure become symptomatic within 2-18 months.6 There are
many factors that contribute to FESS failure, including
extent of disease,4,8,9 incomplete surgery, untreated ana-
tomic obstruction to normal sinus outflow, or continuation
of the underlying disease process, as in cystic fibrosis or
Samter’s triad.7,10
Musy and Kountakis7 reviewed 80 cases of revision
endoscopic sinus surgery and found the after anatomic
causes of surgical failure: middle turbinate lateralization in
78%, incomplete anterior ethmoidectomy in 64%, frontal
recess scar in 50%, incomplete posterior ethmoidectomy in
41%, middle meatal antrostomy stenosis in 39%, retained
uncinate process in 49%, retained agger nasi cells in 37%,
and recurrent polyposis in 37% of cases. Contributing fac-
tors to surgical failure that have been reported include
uncontrolled allergic disease, underlying immunologic dis-
orders, ciliary dyskinesia, and osteitis.2,10,11 These causes
Address reprint requests and correspondence: Michael J. Sillers,
MD, FACS, The Alabama Nasal and Sinus Center, 7191 Cahaba Valley
Road, Birmingham, AL 35242.
1043-1810/$ -see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2005.12.005
should be identified and treated appropriately before con-
sidering revision surgery. If symptoms persist despite max-
imal medical therapy or the search for a nonsurgical etiol-
ogy is inconclusive, then careful comprehensive nasal
endoscopy and repeat computerized tomography (CT) will
often identify a disease focus that is amenable to revision
surgery. Katsantonis et al12 found that repeat CT was 88.2%
specific and 100% sensitive for detecting the cause of sur-
gical failure.
Patterns of surgical failure
When considering revision FESS, perhaps the most impor-
tant feature to recognize is the alteration of normal anatomic
surgical landmarks. The most common anatomic finding in
patients requiring revision endoscopic sinus surgery is scar-
ring between the middle turbinate and lateral nasal
wall.1,7,10 Scar tissue can result in middle turbinate lateral-
ization and maxillary ostium obstruction. Another common
finding in patients requiring revision FESS is incomplete
surgical resection of bony partitions, retained ethmoid cell
walls, portions of the uncinate process, or agger nasi cells
and/or frontal cells.1,7 These structures should be identified
on preoperative CT before embarking on revision surgery.
When there has been either partial or complete resection
of the middle turbinate, orientation of the revision surgeon
is significantly altered. Failure to realize that the turbinate
has been resected and, therefore, “shortened,” may lead to
Sillers and Lay Principles of Revision Functional Endoscopic Sinus Surgery 7

an otherwise avoidable injury to the ethmoid roof, which

will be encountered in a “lower” axial plane than antici-
pated. The medial orbital wall may also be injured because
the surgeon erroneously correlates the inferior border of the
resected turbinate as an axial landmark for the maxillary
sinus ostium.
The contribution of underlying pathology to primary
surgical failure is a critical factor to consider. Kennedy4
found that there was a significant difference in results of
FESS based on the preoperative endoscopic extent of dis-
ease. Normal cavities were seen in 77.3% of the operative
sides without polyposis, whereas only 23.5% of the opera-
tive sides with diffuse polyps were normal. Kennedy4 also
found that frontal recess stenosis and maxillary sinus ostium
stenosis were highest in patients with diffuse polyposis. In
addition, the extent of disease on preoperative CT was a
strongly significant predictor of surgical failure.4,8 For this
reason, any patient undergoing revision FESS for recurrent
nasal polyposis should have had maximal medical therapy,
which may include oral steroid taper and intranasal steroid
sprays, and perhaps several weeks of antimicrobial antibi-
otics before surgery. Such treatment may significantly re-
duce the size of polyps and minimize bleeding, which im-
proves visualization of the anatomic structures.

Treatment options
In patients who have had failure of primary FESS, it should
be emphasized that additional interventions, in most cases,
should be considered relative to their quality of life. As
shown in Figure 1, the FESS surgeon must treat the patient
and not the CT. Two patients with nearly identical radio-
graphic findings may have vastly different symptoms and
quality of life. Surgery is reserved as an option for the
symptomatic patient. The patient also needs to understand
the chronicity of the disease process and that surgery may
be only one aspect of ongoing, long-term treatment. As with
primary surgery, medical therapy should be maximized be-
fore considering revision surgery. In fact, a patient with a
surgical failure may enjoy eventual success once appropri-
ate medical therapy is reinstituted. This therapy may include
prolonged courses of antibiotics, both oral and intranasal
steroids, allergy treatment, and lavage of the nasal cavity
with saline solutions. Although rare, major complications of
FESS can have severe implications for the patient. This fact,
plus the multifactorial nature of the disease, should argue
strongly for ongoing medical therapy as the mainstay of
treatment of refractory chronic rhinosinusitis.4
Similar to primary surgery, patients who have elected to
undergo revision FESS should be instructed to cease all
potential anticoagulants, such as aspirin, nonsteroidal anti-
inflammatory drugs, warfarin (Coumadin; Bristol-Myers
Squibb, Princeton, NJ), and clopidogrel (Plavix; Sanofi-
Synthelabo Inc, Bristol-Myers Squibb/Sanofi Pharmaceuti-
cals Partnership), after appropriate consultation with the
prescribing physician. Also, patients should be educated
that several natural products are known to increase bleeding,
including gingko biloba, green tea, and vitamin E. These
products should be avoided for at least 1 week before
surgery.
Figure 1 Coronal CT showing maxillary and ethmoid sinus
opacification. (A) The patient is symptomatic; (B) the patient has
few symptoms and a relatively good quality of life.
Reduction of inflammation is instrumental to a favorable
outcome, and is likely with culture-directed antimicrobial
therapy, mucolytics, and topical and systemic steroids. Most
patients will have been treated with this strategy before
referral or consideration for revision FESS. However, it
should be emphasized that reducing inflammation may re-
sult in a reduction in intraoperative and postoperative bleed-
ing. A reduction in intraoperative bleeding will enhance the
safety of the procedure simply by improving visualization.
An overall reduction of inflammation may also minimize
the extent of surgery required, allowing the surgeon to focus
on problem areas and enhance the healing process. Equally
important is the continuation of medical therapy after sur-
gery. In patients with diffuse polyposis (Samter’s triad,
allergic fungal rhinosinusitis, eosinophilic rhinosinusitis),
systemic steroids should be tapered slowly during the post-
operative period based on the patient’s symptoms and en-
doscopic examination. Prolonged systemic steroid use is
associated with potential risks, which need to be discussed
with the patient in advance. In some instances, patients may
have steroid dependent disease. Additional postoperative
medical therapy may be dictated by the underlying disease
process and intraoperative cultures.
8 Operative Techniques in Otolaryngology, Vol 17, No 1, March 2006

al14 reported their experience in 25 patients undergoing

revision surgery using CAS. They found no difference in
major or minor complications, but there was an improved
ability to localize important surgical landmarks with CAS
and a subsequent decrease in operator anxiety when com-
pared with patients operated on without surgical navigation.
Important landmarks such as the lamina papyracea, middle
turbinate basal lamella, sphenoid face, frontal recess, and
posterior skull base can be identified by correlating endo-
scopic and multiplanar CT images using a variety of com-
mercially available surgical navigation systems.
In the maxillary sinus/middle meatus region, the surgeon
should look specifically for: retained uncinate; resected,
paradoxical, or lateralized middle turbinate; maxillary an-
trostomy location; and/or infraorbital air cells (Figure 4).
The ethmoid sinus CT should be inspected for retained
ethmoid bulla, prior external ethmoidectomy with associ-
Figure 2 Preoperative CT with computer-assisted surgery head- ated lamina papyracea defect, osteoneogenesis suggesting
set, which shows carotid arteries extending into the sphenoid sinus,
prior mucosal stripping and/or ongoing osteitis, middle tur-
putting them at risk for injury during sphenoid sinus surgery.
binate basal lamella, and ethmoid roof integrity (Figure 5).
The frontal sinus outflow tract should be inspected for
However, even the best medical treatment may fail, at superior uncinate process remnants, the agger nasi cell, and
which point the patient and otolaryngologist should con-
sider revision surgery. The surgeon should have appropriate
expectations and communicate these expectations clearly to
the patient. The surgeon should also consider what would be
performed differently in the revision case compared with
the prior surgery. If the surgeon is simply embarking on an
exploratory mission, the revision surgery will likely fail.
Success of revision FESS is dependent on a cogent preop-
erative plan based on patient symptoms, endoscopic find-
ings, and appropriate radiographic examinations. Finally,
the surgeon should recognize and inform patients that revi-
sion FESS is associated with decreased success and possibly
increased complications.1,6,13
Preoperative imaging is vital in any planned FESS case
but becomes even more important in the revision case. Axial
and coronal images are vital for evaluating danger areas: the
integrity and configuration of the ethmoid roof (Keros I, II,
or III), position of the optic nerve and carotid artery (Figure
2), presence of sphenoethmoid (Onodi) air cells, and the
integrity of the lamina papyracea. Axial-only images may
miss important conditions, such as an ethmoid roof defect
(Figure 3). In many revision cases, the preoperative CT data
will be downloaded into a computer-assisted surgery (CAS)
system. Reconstructed images can be reviewed in axial,
coronal, and sagittal planes. It is important to realize that the
only direct image is the axial image. Coronal and sagittal
images are reformatted and reconstructed from the axial
image. The quality and resulting reliability of the recon-
structed images is dependent on the thickness of the axial
image slice (typically recommended at ⱕ1.5 mm). Comput-
er-assisted endoscopic sinus surgery integrates preoperative
imaging with real-time endoscopic visualization to augment
the surgeon’s knowledge of anatomy and may help to min-
imize patient risk.1
The primary goals of surgical navigation are the reduc- Figure 3 Axial CT of a patient showing opacification in the
tion of complications and improvement in outcomes as a anterior ethmoid sinus (A). However, this view does not accurately
result of early anatomic landmark recognition, and in- depict the true problem, which is a skull base defect, clearly seen
creased surgical precision and completeness. Caversaccio et in the coronal view (B).
Sillers and Lay Principles of Revision Functional Endoscopic Sinus Surgery 9

Figure 5 Axial (A) and coronal (B) CT images showing persis-

tent disease and osteoneogenesis.

Figure 4 Coronal CT illustrating residual uncinate process and

retained ethmoid sinus partitions (A). Coronal CT showing large
posterior fontanel maxillary antrostomy and retained ethmoid par-
titions (B).
frontal recess cells (“uncapped eggs”),15 as well as osteo-
neogenesis (Figure 6).
their success rate for primary surgery. Thus, the potential
for a lower rate of success in revision FESS should be
stressed to the patient during the preoperative counseling
session. Theoretically, complications may be more likely
because of distortion of anatomic landmarks and potentially
more morbid compared with primary FESS. However, most

Surgical technique
Revision FESS may be deemed necessary after the diagno-
sis of refractory rhinosinusitis persists, despite aggressive
medical treatment and previous surgery. The successful
revision FESS begins with excellent preoperative planning
and patient preparation. Informed consent for revision FESS
should emphasize the surgical risks, including, but not lim-
ited to, bleeding, scar formation, persistent or recurrent
infection, blurred vision, double vision, blindness, cerebro-
spinal fluid leak, meningitis, brain abscess, brain injury, and
death. A general discussion of CAS should ensue if that
technology will be used. Jiang and Hsu13 found no differ-
ence in the rate of complications in revision endoscopic
sinus surgery versus primary endoscopic sinus surgery, but Figure 6 Coronal CT depicting frontal recess opacification and
only 65% improvement, which was significantly lower than osteoneogenesis.
10 Operative Techniques in Otolaryngology, Vol 17, No 1, March 2006

case series have not borne this out, instead showing that
complication rates in revision FESS are not any higher than
in primary FESS.
Like primary surgery, revision FESS can be performed
with the patient under local anesthesia with intravenous
sedation or general anesthesia. The choice of anesthetic is
based on surgeon preference. Preoperative mucosal decon-
gestion should begin when the patient is in the holding area
by applying topical decongestant spray to the nasal cavi-
ty(ies) every 5 minutes for 30 minutes prior to arriving in
the operating room. Once the patient is in the operating
room and appropriately anesthetized, oxymetazoline-soaked
cotton pledgets are gently placed into the nasal cavity before
draping the patient. Under endoscopic visualization, local
anesthetic (1% lidocaine with epinephrine 1:100,000) is
injected into the junction of the vertical portion of the
middle turbinate and lateral nasal wall. This injection pro-
duces blanching of the middle turbinate and uncinate pro-
cess. Additional injections along the anterior edge of the
uncinate process and in the middle turbinate basal lamella
are often made. Some investigators4 describe injecting for
vasoconstriction of the sphenopalatine artery.
CAS is often helpful in revision FESS, and there are
multiple systems available commercially. Each system
shares several common features. Images must be obtained
preoperatively according to the manufacturer’s navigation
protocol. These images must then be downloaded to the
navigation workstation and registered. Surgical instruments
require calibration to be recognized within the surgical
volume.16,17 The details of these steps are beyond the scope
of this article. Perhaps the most important step in CAS is
recognizing the system’s “accuracy.” Correlation between
visualized endoscopic landmarks and computer images
should be made. It is helpful to pick anatomic landmarks
that are unlikely to be altered during surgery (ie, maxillary
crest, posterior choanae, and inferior turbinate), which al-
lows for reassessing accuracy as the case proceeds. The
degree to which these endoscopic landmarks and computer
images correlate constitutes a target registration error
(TRE). Ideally, the TRE should be within 1-2 mm.17 If the
TRE exceeds 3 mm and troubleshooting does not rectify the
discrepancy, CAS should not be used.
Two extremely important tenets of revision FESS in-
clude maximal mucosal preservation and early identification Figure 7 The 0° telescopic view of the maxillary sinus shows
of available landmarks. In general, it is helpful to identify mucus recirculation and retained uncinate process (A). After the
the maxillary sinus ostium as an initial step. The maxillary uncinate process is removed, multiple accessory ostia may be seen
sinus ostium serves as a marker for the lateral extent of using the 30° telescope (B). The 30° endoscopic view after the
dissection and locates the lamina papyracea at the superior multiple ostia are connected (C). (Color version of figure is avail-
boundary of the ostium. Finding the ostium is critical and able online.)
can be accomplished with removal of the residual uncinate
process. The maxillary sinus ostium and maxillary sinus
should be clearly visualized, which may require the use of where the anterior wall of the ethmoid bulla attaches to the
30° or 45° endoscopes. Care should be taken to find acces- ethmoid roof in the vicinity of the anterior ethmoid artery,
sory ostia and connect the accessory ostia(um) to the natural a known weak point in the skull base. The basal lamella of
ostium using cutting instruments (Figure 7). The middle the middle turbinate should be penetrated in its inferomedial
turbinate basal lamella and retrobullar recess are also im- segment, preserving the inferior aspect to maintain stability
portant landmarks, and should be identified if present. of the middle turbinate. At this point, dissection has reached
The ethmoid bulla is usually altered, if not absent, having the posterior ethmoid cavity, and the surgeon should iden-
been removed during the prior surgery. Persistent portions tify the skull base (Figure 8). Moving in a posterior-to-
of the anterior, medial, and inferior walls of the ethmoid anterior fashion, the ethmoid roof and lamina papyracea are
bulla should be removed. Care should be taken superiorly gently skeletonized by removing ethmoid partitions.
Sillers and Lay Principles of Revision Functional Endoscopic Sinus Surgery 11

Figure 8 Endoscopic view of the left nasal cavity after landmarks have been “carved” out from what was a collapsed, foreshortened
middle turbinate, and scar tissue between the middle turbinate and lateral nasal wall. (Color version of figure is available online.)

When the sphenoid sinus needs to be entered, the sur- debridement. After the initial follow-up visit, the patient
geon can use the superior turbinate/meatus as a guide to the should return in 2-3 weeks. Subsequent visits and debride-
sphenoid ostium. Alternatively, the inferior portion of the ments should be made based on the underlying disease
superior turbinate may be removed and the natural sphenoid process and extent of the surgery.
ostium enlarged. Caution should be exercised in all areas
where osteoneogenic bone forms because curettage may
lead to avulsion, and subsequent orbital and intracranial
injury. Through-cutting instruments and limited drilling can
be used in areas of osteoneogenic bone formation. However, Conclusion
it is likely that osteoneogenesis will continue if the mucosa
Despite a high rate of initial success in treating chronic
is completely stripped. In revision surgery, it is important
rhinosinusitis with endoscopic sinus surgery, 10% to 15%
that all cell walls are removed so that no disease is left
behind. of patients will have recurrent disease that will require
The revision sinus surgeon should be prepared to address revision surgery. The revision surgeon needs to be keenly
the frontal sinus if necessary. Nowhere is it more important aware that the nasal anatomy has been significantly altered,
to minimize instrumentation and preserve mucosa than in thus increasing the risks of surgical complications. Thor-
the frontal recess/frontal sinus.18 In the revision case, the ough investigation of medical causes of persistent disease
frontal recess may be completely scarred. In this setting, and maximal medical treatment of these causes are imper-
CAS is invaluable for giving the surgeon confidence in ative. Complete history, endoscopic examination, and ra-
removing disease from the frontal sinus outflow tract. Cut- diologic study should be undertaken with any patient who
ting rather than grasping instruments should be used to has primary FESS fail. The preoperative counseling session
remove cell wall remnants. In rare instances, the use of the should stress the potential for a lower success rate in revi-
drill is helpful for removal of obstructing osteoneogenic sion surgery and emphasize the need for prolonged postop-
bone. Patients with recurrent stenosis caused by unilateral or erative medical therapy of the underlying disease process.
bilateral polyp disease, a narrow drainage pathway, osteo-
neogenesis, or any combination of these conditions are
likely to benefit from an extended frontal sinus drainage
procedure, such as a Draf IIb or the endoscopic modified
Lothrop procedure (Draf III) (Figure 9).19
Packing and stents are avoided if possible. Whenever it is
deemed necessary to use packing, as when two abraded
mucosal surfaces are in close proximity to each other, a
resorbable pack is used. There are occasions when stenting
of the frontal sinus ostium may be necessary. Much contro-
versy surrounds the material to use and duration of stenting.
When dense osteoneogenic bone is removed from the fron-
tal recess or if a circumferential injury is created in the
process of opening the frontal sinus, a stent may be used.
Postoperatively, meticulous attention to prevention of
synechiae and scar by both the patient and surgeon is es-
sential for long-term success.4,11,18 The patient should be
seen in the office within 1 week of the surgery, and in-office Figure 9 Endoscopic modified Lothrop procedure using CAS.
debridement should performed. Pediatric patients will most Note communication between the 2 sides of the frontal sinus in the
likely not tolerate the office procedure, thus, the surgeon lower right-hand image and how the tip of the probe is located well
and patient/parent should discuss a return visit to the oper- within the frontal sinus. (Color version of figure is available
ating room within 2 weeks after surgery for postoperative online.)
12 Operative Techniques in Otolaryngology, Vol 17, No 1, March 2006
References
1. Moses RL, Cornetta A, Atkins J, et al: Revision endoscopic sinus
surgery: the Thomas Jefferson University experience. Ear Nose Throat
J 77:190, 1998
2. King JM, Caldarelli DD, Pigato JB: A review of revision functional
endoscopic sinus surgery. Laryngoscope 104:404-408, 1994
3. Schaefer SD, Manning S, Close LG: Endoscopic paranasal sinus sur-
gery: indications and considerations. Laryngoscope 99:1-5, 1989
4. Kennedy DW: Prognostic factors, outcomes and staging in ethmoid
sinus surgery. Laryngoscope 102:1-18, 1992 (suppl 57)
5. Smith LF, Brindley PC: Indications, evaluation, complications, and
results of functional endoscopic sinus surgery in 200 patients. Otolar-
yngol Head Neck Surg 108:688-696, 1993
6. Lazar RH, Younis RT, Long TE, et al: Revision functional endonasal
sinus surgery. Ear Nose Throat J 71:131-133, 1992
7. Musy PY, Kountakis SE: Anatomic findings in patients undergoing
revision endoscopic sinus surgery. Am J Otolaryngol 25:418-422,
2004
8. Chandra RK, Palmer JN, Tangsujarittham T, et al: Factors associated
with failure of frontal sinusotomy in the early follow-up period. Oto-
laryngol Head Neck Surg 131:514-518, 2004
9. Bhattacharyya N: Computed tomographic staging and the fate of the
dependent sinuses in revision endoscopic sinus surgery. Arch Otolar-
yngol Head Neck Surg 125:994-999, 1999
10. Richtsmeier WJ: Top 10 reasons for endoscopic maxillary sinus sur-
gery failure. Laryngoscope 111:1952-1956, 2001
11. Stammberger H: Endoscopic endonasal surgery– concepts in treatment
of recurring rhinosinusitis. Part I. Anatomic and pathophysiologic
considerations. Otolaryngol Head Neck Surg 94:143-147, 1986
12. Katsantonis GP, Friedman WH, Sivore MC: The role of computed
tomography in revision sinus surgery. Laryngoscope 100:811-816
1990
13. Jiang RS, Hsu CY: Revision functional endoscopic sinus surgery. Ann
Otol Rhinol Laryngol 111:155-159, 2002
14. Caversaccio M, Bachler R, Ladrach K, et al: Frameless computer-
aided surgery system for revision endoscopic sinus surgery. Otolaryn-
gol Head Neck Surg 122:808-813, 2000
15. Bradley DT, Kountakis SE: The role of agger nasi air cells in patients
requiring revision endoscopic frontal sinus surgery. Otolaryngol Head
Neck Surg 131:525-527, 2004
16. Dubin MG, Kuhn FA: Stereotactic computer assisted navigation: state
of the art for sinus surgery, not standard of care. Otolaryngol Clin
North Am 38:535-549, 2005
17. Anon JB: Computer-aided endoscopic sinus surgery. Laryngoscope
108:949-961, 1998
18. Stammberger H: Endoscopic endonasal surgery–Concepts in treatment
of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngol
Head Neck Surg 94:147-156, 1986
19. Citardi MJ: Computer-aided frontal sinus surgery. Otolaryngol Clin
North Am 34:111-122, 2001