Revision Sinus Surgery Poses Unique Challenges

Revision endoscopic sinus surgery (RESS) has challenges that often are not seen in primary surgeries. Still, there are tips to keep in mind when working with issues such as altered anatomy, a lateralized middle turbinate or return polyp patients.

To address these issues, ENToday asked two leading surgeons for their take on RESS. Michael Friedman, MD, Professor of Otolaryngology at Rush University Medical Center in Chicago, and Raj Sindwani, MD, Assistant Professor of Otolaryngology at St. Louis University, discussed which patients benefit the most from RESS, when it is indicated, its limitations, and what the future holds.

Indications for RESS

Generally, RESS is part of the treatment for chronic sinusitis, said Dr. Friedman. While there are data on the number of people with chronic sinusitis (30 million in the United States), and the number of sinus surgeries performed in general (about 300,000 annually), no one knows exactly how many of those surgeries are revisions-estimates in the medical literature vary from 20% to 60%.

Chronic sinusitis is the most common chronic condition in the United States, Dr. Sindwani said. Studies show that the quality of life of patients with chronic sinusitis is worse than COPD, asthma, and even things like chronic back pain, he said. In his own tertiary level practice, revision cases outnumber primary cases.

There are two types of patients who return for sinus surgery: the polyp patient, and those with no polyps. Patients who have polyps are challenging because of the high recurrence rate. In fact, when patients go in for primary polyp surgery, it’s a good idea to discuss the fact that the disease is likely to recur and that further surgeries will be needed. That way, when second, third, or fourth surgeries are needed for polyps, previous surgeries will look less like failures in the eyes of the patient, said Dr. Friedman.

Patients who have polyps have an intrinsic disease of their sinus lining. They almost always have some sort of allergy problem and a significant percentage have an allergic fungal sinusitis…. Surgery can’t correct the underlying problem, Dr. Friedman said. Returning polyp patients become surgical candidates only after a rigorous arsenal of treatments to fight the disease has had an insufficient effect.

In some ways, repeat surgeries for polyp patients aren’t true revisions, said Dr. Sindwani. You’re not really revising per se, you’re going back in because new polyps have grown, he said. With polyp patients, going back in sometime in the future is part of the overall treatment plan-unlike other types of revision surgeries.