Toward Better Outcomes: Avoid revision surgeries in chronic rhinosinusitis patients

For many patients with chronic rhinosinusitis, functional endoscopic sinus surgery (FESS) has provided much needed relief from a condition that, by its daily aggravation, can significantly reduce quality of life.

In some patients, however, symptom relief is not achieved even after surgery, or the disease recurs and patients must return for revision surgery. What are the main reasons for revision surgery? How can it be avoided?

Answering these questions is anything but straightforward. A failed surgery in one patient’s eyes may be a success in another’s, and strict criteria for defining what success or failure means clinically are somewhat arbitrary given that the outcome desired—improved quality of life—is not an exact quantifiable outcome.

Despite this ambiguity, experts point to two primary reasons sinus surgery fails. “The two main reasons for FESS failure are doctor-related and patient-related,” said Robert Kern, MD, chief of rhinology at Northwestern University’s Feinberg School of Medicine, Chicago, Ill. In other words, failure results from issues related to the surgical technique and issues related to the chronic nature of the disease.

Surgical Technique

Most of the reasons sinus surgery fails relate to incomplete surgery, according to James Palmer, MD, director of the Division of Rhinology at the Hospital of the University of Pennsylvania in Philadelphia. “The biggest improvement in FESS surgery is the understanding that complete surgery improves outcomes,” he said. Partial surgery, which includes incomplete removal of all bony partitions and incomplete opening of the sinuses, may lead to a worse result, he said.

According to Dr. Kern, opening up all the sinus cells is particularly critical for patients with extensive disease. “If a patient has nasal polyposis, a complete ethmoidectomy will give the best outcomes,” he said, emphasizing that strong surgical skill is required for this.

Agreeing that surgical skill is key to opening up all the sinus cells and that this is critical to improved outcomes, Lanny Garth Close, MD, chairman of the department of Otolaryngology/Head and Neck Surgery at Columbia University in New York, said that some surgeons shy away from opening certain sinus cells, particularly in the areas of the eye and brain, because of the increased potential for morbidity in these areas. “Often, surgeons feel that it is better to leave some cells untouched rather than harm the patient,” he said, despite the potential for a lower success rate.

Although Dr. Close believes that complete removal of all bony partitions (i.e., complete surgery) leads to the best long-term results, other surgeons lean toward only opening those cells that show up on imaging as diseased. “Most patients probably do not require every sinus opened,” said Martin Citardi, MD, chair of the department of Otorhinolaryngology-Head & Neck Surgery at the University of Texas Medical School at Houston, adding that the surgery only needs to be comprehensive enough to deal with the disease at hand.