Revision Sinus Surgery and Why Sinus Surgery Fails

Approximately 16% of the population suffers from at least one sinus infection per year. Many who have recurrent acute sinusitis (4 or more sinus infections per year) or those with chronic sinusitis (infections lasting over 3 months) will have sinus surgery which can dramatically improve their quality of life. Unfortunately, 5 to 20% of those patients will continue to have secondary sinus infections and will require a revision sinus surgery, RESS. Infections can occur immediately after surgery or even years later. Ultimately this is caused by inflammation or blockages in the sinuses. The sinuses include maxillary, ethmoid, frontal and sphenoid. The following are many of the major reasons why each of the sinuses continues to have infections.

Maxillary Sinus:

This sinus is located in the cheek under the eye on both sides. Symptoms of maxillary sinusitis include cheek and tooth pain, facial pressure, fatigue, and thick discolored drainage. Reasons for maxillary sinusitis after surgery include:

• Failure to completely open the natural drainage pathway of the sinus which can cause the return of sinusitis. This opening called the maxillary ostium can scar closed, be pressed closed by a large middle turbinate, or obstruct from swollen mucosa or a polyp. Widely opening the natural drainage pathway can treat this.
• An opening incorrectly made further back in the maxillary sinus than the true opening can cause mucus and pus to recirculate into the sinus. A second sinus surgery connecting these true and false openings will correct this.
• Sometimes the tissue in the sinus is too damaged to work and the sinus needs to be more widely opened to drain. Extending the opening posteriorly in the sinus will allow medication and saline rinses to enter and drainage to leave.
• A deviated septum can press the middle turbinate laterally which can block the maxillary sinus. A failed septoplasty may require a revision septoplasty. Straightening the septum may help allow opening of the sinus.
• Dental infections are responsible for a high percentage of isolated maxillary sinus infections. The infection does not resolve until the infected tooth is appropriately treated by your dentist or oral surgeon.

Ethmoid Sinuses:

These are composed of 3 to 10 “grape-like” bony separations (cells) that extend between the eyes on either side going deeper into the nose. Symptoms of ethmoid sinusitis include eye pain, headaches, fatigue, and yellow drainage into the nose and throat. Persistent or chronic causes include:

• Incomplete ethmoid sinus removal can be a cause of failed sinus surgery. Not opening or removing all of the bony ethmoid separations can leave the closed compartments infected. Partial removal can leave narrow areas in the ethmoids that can be blocked. Revision Fess surgery involves more extensive removal of the bony partitions.
• Return or regrowth of nasal polyps. Even with a complete surgery, nasal polyps can return. Medication and allergy shots or environmental controls may slow or reverse polyp growth but if symptoms or infections worsen then periodic polyp removal may be necessary.
• Extension and progression of an ethmoid disease. For a first surgery just opening and removing the anterior ethmoids may be all that is required. Sinusitis can worsen over time and the posterior ethmoids may become involved. Removing the posterior ethmoid cells can improve symptoms in this case.
• A deviated septum can prevent the ethmoid sinuses from being adequately ventilated which can allow for congestion and infection of the sinuses. A failed septoplasty may require a revision septoplasty. Straightening the septum may allow appropriate ventilation of the ethmoid sinuses. This second septoplasty may also improve breathing function.
• Maxillary sinus disease can cause inflammation to spread to the ethmoid sinuses. Widely opening the maxillary sinus true opening can decrease this inflammation.

Frontal Sinus

These sinuses begin between the eyes and extend upward into the forehead. The left and right side frontal sinuses are divided by a thin bone. Symptoms include frontal headaches on one or both sides, discolored nasal drainage, forehead pressure and fatigue. The openings are very small and subject to recurrent or chronic sinus infection even after a successful primary surgery. Causes requiring revision frontal sinus surgery include:

• Incomplete anterior ethmoid surgery will leave the frontal sinus drainage tract blocked. Completion of the anterior ethmoidectomy will improve drainage.
• Partially removing the agar nasi, which is a large sinus that blocks the frontal sinus drainage, can allow for frontal sinus infections to recur. A second sinus surgery with complete removal of the agar nasi cell can be helpful.
• Polyp blockage or scarring of the frontal sinus opening blocks the frontal sinus. Removing blockages promotes drainage and allows medication to enter the frontal sinus. Sometimes a larger procedure is needed to connect both frontal sinuses through a wide opening.
• Congestion of the frontal sinus tissue can be caused by allergies, medicines that make the mucosa swell, chemical and physical irritants, bacteria and viruses, flying or scuba diving, and other causes. Controlling environmental factors, allergy treatment or removing the cause of inflammation can improve symptoms.

Sphenoid sinuses

These sinuses are located on the left and right deep inside the nose. They are surrounded by major vessels and nerves including the carotid artery and optic nerve. The brain and pituitary gland are located on the superior surface of the sinus. Symptoms of sphenoid sinusitis include a persistent drainage down the throat, discolored sputum that you cough-up, headaches in the middle or back of your head and fatigue. Causes requiring revision sphenoid surgery include:

• Incomplete sphenoid sinus opening which can scar closed or the mucosal lining may reform over the sphenoid opening. Widely opening the sphenoid sinus and removing the small bony partitions will treat this.
• Blockage by the superior turbinate, located just in front of the sphenoid sinus, can block the true sphenoid sinus opening and prevent drainage. Removing the inferior portion of this superior turbinate may provide sphenoid sinus drainage.
• Polyps or thickened tissue in the sphenoid sinus can prevent drainage and their removal can improve sphenoid sinus ventilation. Extreme caution must be observed as there is close proximity to many important vascular and neurological structures.

What can be done if I keep getting sinusitis?

Sometimes sinuses may be completely surgically opened and infections may continue. The goal in this situation is to treat the inflammation and minimize symptoms. An allergy and autoimmune workup may determine the cause. Certainly, a second opinion with an independent Otolaryngologist may add additional information. Chronic sinusitis can be a lifetime battle requiring daily awareness and treatment.

Is revision sinus surgery in NY or NYC covered by my insurance?

Sinusitis causes a worse quality of life than COPD and heart disease. Your insurance recognizes this and will most likely provide benefits for an NYC revision sinus surgery or revision septoplasty surgery. Our office will check your benefits and let you know what they are. We have a no surprise billing policy for sinus revision surgery so you can make an informed decision on your care.

How can your office help me with a sinus revision surgery?

Our office will provide a thorough and thoughtful history, a physical exam including evaluation of the sinuses with an intranasal endoscope, and appropriate imaging studies which can help determine if there is a structural or inflammatory cause for your sinusitis. We can determine if you would benefit from revision sinus surgery after failed sinus surgery or a second septoplasty after failed septoplasty. If you feel that you may require revision sinus surgery or revision septoplasty, please feel free to contact our office for a second opinion.