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BackTable / ENT / Podcast / Transcript #30
Podcast Transcript: Revision Endoscopic Sinus Surgery
with Dr. Ashleigh Halderman
We talk with Rhinologist Dr. Ashleigh Halderman about Revision Endoscopic Sinus Surgery, including patient selection, pre-op planning, and endoscopic technique. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Presentations of Patients Considering Revision Sinus Surgery
(2) Pre-Operative Assessment: Imaging, Endoscopy, and Exam
(3) Medical Therapy Regimens of Patients Undergoing Revision Sinus Surgery
(4) Importance of an Accurate Diagnosis Prior to Pursuing Surgery
(5) Counseling for Patients with Unspecified Causes of Headache or Sinus Pain
(6) Candidacy and Equipment Setup for Revision SInus Surgery Cases
(7) Operative Techniques and Considerations in Revision Sinus Surgery
(8) Special Considerations and Mistakes to Avoid Intra-operatively
(9) Post-Operative Pearls for Sinus Surgery Patients
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[Ashley Agan MD]
Hi, everybody. Welcome to the Back Table ENT Podcast. Our goal here is medical education in otolaryngology. We seek to accomplish this through conversations with experts in the field, and we hope that you can take this information and apply it to your practice. My name is Ashley Agan, and I'm a general ENT practicing at UT Southwestern Medical Center in Dallas.
[Gopi Shah MD]
And my name is Gopi Shah. I'm a pediatric ENT at UT Southwestern in Dallas. How are you doing today, Ash?
[Ashley Agan MD]
So good, Gopi. How are you?
[Gopi Shah MD]
I'm doing well. I'm still rinse, pre-rinse, got the sinus, but that's okay, it's clearing up with my handy-dandy lozenges. We have a really, really special, awesome, awesome guest today, Dr. Ashleigh Halderman, who is a friend and colleague of ours. She's going to talk to us today about revision endoscopic sinus surgery. Dr. Ashleigh Halderman is an assistant professor in the department of otolaryngology at University of Texas Southwestern Medical Center with us here in Dallas. After receiving her medical degree from Boston University, Dr. Halderman completed her residency in otolaryngology at the Cleveland Clinic. She did her fellowship in laryngology and skull base surgery at Johns Hopkins University School of Medicine. Ashleigh, again, is here to talk to us today about revision endoscopic sinus surgery. Welcome to the show, Ash, how are you doing?
[Ashleigh Halderman MD]
Thank you ladies. It's so nice to see you. You don't get to do that very often these days.
[Gopi Shah MD]
I know.
[Ashley Agan MD]
I know.
[Gopi Shah MD]
Your hair has grown. I haven't seen it long. I like it.
[Ashleigh Halderman MD]
I know. I started the pandemic with a pixie is all I could say. Went through a lot of different phases, like the pandemullet and...
[Gopi Shah MD]
Now it's a long bob.
[Ashleigh Halderman MD]
Yeah.
[Gopi Shah MD]
We know you pretty well. But for those of our listeners who may not know you as well, could you tell us a little bit about yourself, a little background, and then about what kind of practice you have?
[Ashleigh Halderman MD]
Sure. So I grew up in the great State of Kansas. Went to Kansas State University where I was a walk-on for the track team. And I focused on the long and triple jump, but I always joke that coach would be like, "Okay, real athletes, go hit the track. Halderman, go hit the gym." Because I got to the gym, I mean the books, because I was the academic GPA booster for the team. And met my-
[Gopi Shah MD]
You had to pull your weight somehow.
[Ashleigh Halderman MD]
I know. And I did. I tutored a lot of people. But it was so awesome. It was such a great time. And then when I moved to Boston, I met my husband Brett, and he's been generous enough to jaunt around the country with me in the quest of rhinology training and then a rhinology job. And we have three dogs that we picked up along the way. Last dog was not something he wanted. He was gone when I brought it home. And so anyway, so it's a little bit about me.
And my practice is a combination of general rhinology and skull base surgery. And I think probably the skull base... I mean, I really love everything that I do. People will always ask me, is there a favorite thing that you do? And I'm like, "No, not really," because there's something that I enjoy in every case or every surgery that I do. The things that I like about, I guess, skull base and also revision sinus surgery is that there's no clear roadmap and you don't know what you're going to get and there's some kind of creative thinking and some decision making on the fly that goes into those types of surgeries. Even if you have imaging and whatnot and you've done endoscopy in the clinic, you just never know what you're going to find.
My fellowship director, I think coined the best term, which is forensic rhinology. That's what he would say whenever we were doing a revision case that was not his own revision, it was coming in from somewhere else. You kind of had to do a little bit of forensic rhinology. And I don't know if this should be included or not, but when I was a second year resident, one of our chiefs was going through and guessing what we would go into. And he said, "I think you're going to go into rhinology." And at the time I didn't really know much about it. I remember saying, "I want to be a real surgeon." So I think that's a good lesson and don't speak until you know what you're talking about.
[Gopi Shah MD]
And look at you now.
[Ashleigh Halderman MD]
Right now I know I'm not a real surgeon. No, I'm kidding. At least based on my PGY-2 impression of what rhinology was.
(1) Presentations of Patients Considering Revision Sinus Surgery
[Gopi Shah MD]
So getting into it these patients presenting who may or may not need revision sinus surgery, what does that look like in your clinic? What kind of patients are you seeing and what tends to be the chief complaints and problems that are going on? Can you tell us more about that?.
[Ashleigh Halderman MD]
It can be a variety of issues. From revision surgery, if there was maybe not complete dissection, and they're still having a lot of the same symptoms and a lot of recurrent exacerbations or infections, if they have recirculation, then they're talking about a lot of really thick drainage that just won't go away. And sometimes people are presenting with symptoms secondary to a mucocele or even a mucopyocele. So I think that a lot of times they're coming in because the issues that they sought surgery for in the first place didn't really resolve, or even in the worst setting, got a little worse or they developed new symptoms. And I think one of the most important aspects of meeting a patient for the first time who has had prior sinus surgery and is still having problems is asking them, what do they do for their sinuses?
And I would probably split the population into two different groups, one of which is they're not doing any maintenance therapy, so no rinses, no intranasal steroid sprays. And you always start them with that and see if that's enough. And I'd say that in a fair number of people, that's enough and in other people it's not. But you have to tease out what they've been doing, what they've been educated on, what they've been told, and always what they interpreted that as.
[Ashley Agan MD]
Yeah, absolutely. I feel like some patients think about sinus surgery as a cure. I had surgery and that's all I know. Now I'm done, I don't need to do anything. Sometimes there's some reduction that needs to happen.
[Ashleigh Halderman MD]
It's a very good point, especially for your polyp patients or allergic fungal sinusitis. I can't tell you how many people's jaws drop when I'm like, "Surgery is not curative and you have to continue on a maintenance regimen or they will come back." And they're like, "Nobody ever told me that," or they just didn't interpret what was being said to them as that. So that's a great point, Dr. Agan.
[Gopi Shah MD]
For the patients that come to you, do you look at CRS with polyps differently than CRS without polyps when they need revision surgery? Just because with polyps, you almost expect it because polyps come back. Is there a different way in which you think about those patients and their need for revision?
[Ashleigh Halderman MD]
I probably approach it in somewhat the same manner, which is that I always like to get an updated CT scan so that I can understand what the extent of the prior surgery was. In revision cases, an incomplete ethmoidectomy can be present in up to like 75% of revisions. And so let's say for polyps, that's a pretty big deal. I mean for CRS, it is as well, but that's the first place... Well, first place I start is what have you done? What type of medical therapy have you stayed on maintenance wise? For polyp patients, I'm always asking them if they've done topical steroids or budesonide rinses, and I find that a lot of them maybe started out doing it and then stopped when they felt better or they never did. So again, making sure that they're on the appropriate therapy.
So the first thing is making sure they've been doing what they should be doing. Probably number two is doing the physical exam and an endoscopy to get a little bit of an understanding. And then I supplement that with a CT scan. And with a CT scan, I'm trying to just understand the extent of the prior surgery, where their trouble areas might be. And that changes my plan and view, I think, more than anything and drives the next steps.
[Ashley Agan MD]
Yeah. That makes sense. Do you find that the patients who maybe need more revision surgery or have had a lot of bone left behind, do those tend to be polyp patients just because of the nature of that surgery, maybe people are more likely to leave bone behind because of visualization during surgery or is it a mixed bag?
[Ashleigh Halderman MD]
I'd say it's more of a mixed bag, actually. It's a great question. I haven't really ever observed any differences. I tend to see the same mistakes made in revision cases. And I think that there's some technical aspects that lead to this cascade of this first step impedes the next step, which impedes the next step and whatnot. And I think it's also compounded by the fact that we're operating near really vital structures, the orbit and the skull base, and nobody wants to damage either of those structures. And so the instinct is to stay as far away from them as possible. And I think that that leads to a lot of the issues that I see in patients that need revision surgery. So when I'm educating our residents, I try to say, "Think about parotid surgery, why do you find the facial nerve?" Well, you find the facial nerve to protect the facial nerve. And so it's the same thing with sinus surgery. I find the orbit, I find the skull base and that way I can keep my eye on them and make sure I'm protecting them.
[Gopi Shah MD]
So you lead us to a good point in terms of some of the same mistakes or things. Can you go through what you find maybe on a CT and then what you also maybe then see in the OR in terms of some of the same patterns that you see?
(2) Pre-Operative Assessment: Imaging, Endoscopy, and Exam
[Ashleigh Halderman MD]
Yeah. So the CT scan, there's a lot of little minute details that you can't completely tease out on the CT scan. So that's where the nasal endoscopy is really important. So when I first start off in clinic and nasal endoscopy, I'm looking to see if the middle turbinates are lateralized, is there residual uncinate? Do I see a posteriorly based small antrostomy that looks like it probably doesn't extend to the natural os, which is probably covered by some residual uncinate. But if those things are present, you can't really see much past that. So that's where the CT scan comes really handy. And I'm looking to see what the ethmoid partitions look like? How much of a dissection was done there, the frontal recess, obviously the anatomy can be really challenging there. And if you haven't done a complete uncinectomy or a total ethmoid, you probably didn't open up into the frontal. So you're assessing what the frontal recess looks like and what the degree of dissection that occurred up there.
You're also looking for areas of osteitis, which you often see in cases of revision sinus surgery. And a lot of times that's maybe a sign that there'd been some mucosal stripping, but it can also be a sign of prolonged and chronic inflammation. So you're trying to get an idea of how much there is of that in the sinuses. And that's always a bummer to see, because it's really hard to remove that. The scarring is going to be not great, the healing is not going to be great and it will really prolong the surgery while you're doing it. It makes it harder.
[Ashley Agan MD]
And when you're seeing these patients in clinic, I assume you're using a rigid scope for your exam most of the time. And do you use zero degree, 30 degree? What are your specifics around that?
[Ashleigh Halderman MD]
Yeah, absolutely I'm using a rigid scope because the visualization and the picture is so much better than a flexible scope. And in anybody who's had prior sinus surgery, I use a 30 degree scope without fail. And you can use a zero degree, but I really think you get so much better information and detail with a 30 degree scope than you do with a zero, because you look around corners and look up. So that's my go-to for people who have had prior sinus surgery.
[Gopi Shah MD]
And so let's say you have the patient that has the CRS, no nasal polyps that you see that there's some residual uncinate or maybe that posterior antrostomy and you can't tell if it's connected. How do you manage them? I mean, do they definitely need to go back to the OR are you able to avoid a revision or kick the can if you will, a little bit further? What are some of your nonsurgical tricks for these patients?
[Ashleigh Halderman MD]
Again, it just comes down to what are they doing for their maintenance? So always try every patient on maintenance therapy. If they have an active infection at the time that I see them, in CRS, I'll treat them with some antibiotics and get them started on rinses and intranasal steroid spray. And then I see them back after a month and see how they did. And all of our decision making goes based on how they are doing. This is a symptom driven process and a quality of life thing. And I tell patients, only you can tell me what's good enough and what's not good enough. I have certain logistics that I lay down and in my polyp patients, I don't like to do more than two courses of oral steroids a year because you have to start worrying about the long term side effects of that. And especially in older patients and in female patients, you have to worry about bone density. It actually can really suck the calcium right out of the bones.
So I do have some hard limits as far as polyps go. And if I see any evidence of a mucocele, then I am going to be inclined to recommend surgery because this is something that just surgically you have to fix. And the same thing with fungal debris or fungal material, fungal ball, anything like that, I'm going to recommend surgery much sooner. But with recirculation and just general drainage and poor functioning of the sinuses, I guess, I do think rinses can mitigate a lot of those issues and help people control them. Then it becomes a patient preference thing. And I tell them because sometimes they just don't want to do the rinses and I'm like, "Well, if I did sinus surgery on you, guess what, you're still going to have to do the rinses. This is a chronic inflammatory disease that you're going to always have that nothing's going to cure. So you have to do something to maintain it."
(3) Medical Therapy Regimens of Patients Undergoing Revision Sinus Surgery
[Ashley Agan MD]
And just breaking down some of those treatments that you discussed. So for example, with your steroid sprays, when do you prefer a steroid spray versus something like a budesonide rinse? Do you have patients put the budesonide in their rinse or do you have them apply it directly to the nose?
[Ashleigh Halderman MD]
Great questions. Steroid rinses I'm usually saving for polyps or AFS, allergic fungal sinusitis and nasal sprays I'm using in people with CRS without polyps and in those who have pretty significant allergic rhinitis. Basically my thoughts are... and there have been good studies that show that intranasal steroid sprays distribute well to the anterior and inferior portions of the nasal cavity. Whereas rinses tend to get into the sinuses much better. So if I'm needing to deliver steroids up into the ethmoid cavity, if you will, or wherever, then I'm going to go for budesonide rinses. And I do have them put the budesonide directly into the rinse. I have a couple of reasons why. Well, number one, there have been good fluid dynamic and cadaveric studies that show that the delivery of these topical things depend on the fluid column. So you're looking at the volume and rate at which saline is delivered.
And if you think about it, a fluid column has to develop to be able to distribute to these different layers. And so in my opinion, if you do be budesonide directly into the nasal cavity, it's not quite getting in maybe as well. There's also a lot of... if you have to do the intranasal budesonide, which, hey, if a patient can tolerate rinses or if they have specifically their one symptom is hyposmia, then you can go with the direct intranasal budesonide, but that has to be positionally delivered and it adds this layer of dedication and stuff that patients have to go through to do this. And I wonder about how well they adhere to that.
[Ashley Agan MD]
By that you mean that they have to hang their head upside down after they've put in their nose?
[Ashleigh Halderman MD]
Yeah. And they have to sit there for a few minutes and it's unpleasant and it just takes extra time to do. And everyone's adding stuff to their daily routine, they just want to simplify. So I try to make it as easy as possible. Adherence and compliance is really important. So I throw them a bone.
[Gopi Shah MD]
I agree. I have my patients just do it directly in the rinse too, because I need them to be consistent, and that extra 10 minutes isn't going to be sustainable for some of the patients.
[Ashleigh Halderman MD]
It's not a small thing.
[Ashley Agan MD]
It adds up.
[Ashleigh Halderman MD]
It sure does.
[Ashley Agan MD]
Before moving on, I also wanted to ask you about your steroids and your antibiotics. So for your courses of oral steroids, what is your preference; prednisone, methylprednisolone, for how long and do you taper, et cetera. For your antibiotics, do you have a particular empiric antibiotic that you use or is it culture driven or does it just depend?
[Ashleigh Halderman MD]
So as far as steroids go, I like Medrol a little bit better than prednisone. And I was taught by my very brilliant fellowship director, Dr. Lane, that Medrol actually more closely chemically resembles our own cortisol, and so there are fewer mineralocorticoid side effects associated with it. And this might be completely biased, but I do think people tolerate it better. Now, some people are tried and true on prednisone and they don't want to deviate and that's fine. Then I'll let them have prednisone. I do collective decision making with the patient. But Medrol is my go-to and I have a variety of bursts and tapers that I will prescribe, depending on when the last time was it a patient took a steroid, what the doses are that they've responded to in the past, how bad their polyp burden is, those kinds of things.
But typically I'll start at 32 milligrams of Medrol and then taper down to 24, 16, 8 and stop. And I'll do anywhere from four days on each dose up to seven days on each dose. And as far as antibiotics go, my go-to is doxycycline. Again, I think patients tolerate it very well and I see very few side effects. There can be some GI upset, but I tend to see less gut aggravation than I do with Augmentin or amoxicillin. And based on the literature, doxycycline has this nice anti-inflammatory factor that's contributing as well and is anti-staph. And so that's what I go for in most patients. And of course you need to counsel them that this being Texas and now it's summer, they need to avoid going out into the sun when they're on it or they get the photosensitivity reaction.
If they are allergic to doxycycline or it interacts with their other medications, then I'll a lot of times do Ceftin. And sometimes if a patient has... typically, I don't do this with polyp patients, but in some patients I'll do Biaxin. And again, I ascribe to the theory that chronic sinusitis is a purely inflammatory process and that infections are a sequela of that. And so if you target the inflammatory cascade, I do think you're going to get more success with your treatment. And so then sometimes I'll do Biaxin. Sometimes I'll choose Biaxin because of the immunomodulation that it provides. And sometimes in patients who are getting some recurrent infections and they don't want to do surgery, then I'll have them add mupirocin to their rinses. And I have a lot of people who have had a lot of great success on that and really, really liked that. And it's a great way to avoid systemic antibiotics.
[Gopi Shah MD]
For the mupirocin and the rinses, Ash, how do you direct them to do it? A dime size amount in the rinse bottle? How do you tell them to put it in and how often, and is it just for a certain amount of time or is it ongoing?
[Ashleigh Halderman MD]
First of all, you need to make sure that you're not prescribing mupirocin nasal because that's actually petroleum based and it's not water soluble. So you have to do just regular mupirocin ointment, which is water soluble. And I always counsel patients that it's just barely water soluble, so it does take a little bit of effort. Most people find that if they heat it up, it works a little bit better and it melts a little bit better. You have to shake it really vigorously. I have them use it twice a day and I have them put about what I say is the amount of toothpaste that you put on your toothbrush. So it ends up being about the first joint of your index finger is a good amount. Twice a day on that. And I have some people who do it just whenever they start to get symptoms, and then they're able to head off a full blown sinus infection, others like folks that have had radiation and have a lot of crusting and issues induced with that. Anybody who has poor ciliary clearance and that can come from a variety of reasons, not just cystic fibrosis, but other disease processes, they're doing it more frequently or doing it on a regular basis.
Oh, and Dr. Agan, you had asked me earlier about cultures. I tend to not get cultures in straightforward cases. When I'm taking a culture, a lot of times it's because I'm considering that potentially this person needs to be on a topical antibiotic and may have a lot of resistance. And so those are mostly my CF patients, cystic fibrosis patients.
[Ashley Agan MD]
What kind of topical antibiotics are you doing? Or just mupirocin would be one example, I guess.
[Ashleigh Halderman MD]
Yeah. And mupirocin is definitely the one I use the most. There's not a lot of evidence actually for the use of topical antibiotics in patients. The ICAR:Rhinosinusitis statement actually recommends against fungal medications and irrigations. I never do that. For my CF patients though, to avoid IV antibiotics for a sinus infection because IV antibiotics aren't very effective for sinusitis and most people, it depends on what they're growing out. And I'd say a lot of times some pseudomonas and potentially some staph and I'll put them on some tobramycin more often than anything else.
[Gopi Shah MD]
And that's something that the pharmacy mixes in the saline for the patient.
[Ashleigh Halderman MD]
Yeah. We have compounding pharmacies that we order from. And typically they give them capsules. So they break the capsule open and sprinkle a powder into the saline, and then they shake that up.
[Gopi Shah MD]
And so when we're saying topical, we're not talking about nebulized antibiotics, correct? Just to clarify that.
[Ashleigh Halderman MD]
Yes, I'm having them put them in the rinses. I have a few patients who have sensory disorders and the rinses are just not something that they can do. And so in those instances, the nebulization was more successful. And so I'll defer to what my patient is able to tolerate and do in special circumstances.
[Ashley Agan MD]
What do you think about these powered nasal irrigation systems? Are they any better? Do you have any patients that use them or really like them?
[Ashleigh Halderman MD]
Yeah. So there's not been really head to head studies comparing these powered ones to the tried and true neti pot or the rinse bottle. And in my own practice, I have seen individuals who just decided to switch over and start using the mechanized or motorized rinses. And they started to accumulate mucin and goo in their maxillary sinuses. And I haven't studied this, so this is just my own personal opinion, but in post-operative patients, I counsel them to stick with the rinse bottle because I have my doubts that the motorized units can build that same fluid column. It's a flood and it's not a stream. And so something's just producing a stream, it's probably not going to get into the sinuses like we want it to.
(4) Importance of an Accurate Diagnosis Prior to Pursuing Surgery
[Gopi Shah MD]
So before we move on to discussing parts of the surgery specifically, is there anything else from a maximizing medical management standpoint that we have forgotten to ask you about, or that you want to just make sure that our listeners take home?
[Ashleigh Halderman MD]
I think one more point that I'll make is, whenever you're seeing a person for revision sinus surgery, you also need to question and make sure that the correct diagnosis was made in the first place. So if a patient's coming to you and they've got really severe headaches, and that's why they had sinus surgery, and you look at the CT scan and there's just nothing really that correlates with those headaches, then that's not going to be a successful revision sinus surgery because that's not the issue. I actually just had a patient who had several sinus surgeries for sinus symptoms that we think are due to chronic graft versus host disease. I mean, I think rhinology is all about being very detail oriented. And I have the luxury of being very selective in who I operate on and I don't want to operate on a person who's not going to get a benefit.
The other thing that you have to really tease out is who's coming in with recurrent viral illnesses versus true chronic sinusitis. And I'm less confident that any surgery of mine is going to make a huge difference on this person who's getting recurrent viral infections. That's just going to happen no matter what. So I think about going back and really thinking about... I'll ask the patients, "So what initially led you to have sinus surgery? What symptoms were you having? What was going on? And what got better after surgery and what didn't? So what have you tried? What have you done?" And if there's any question about whether their sinus symptoms are truly due to chronic sinusitis or underlying sinus disease, I like trying to capture a CT scan at a time when they're actively having symptoms but have not started any medical therapy.
So what I'm trying to do there is capture them exactly when they are symptomatic, and I'm correlating whether or not there is any underlying radiographic sinus disease. And I know a lot has been taught to us and we're all taught to do post-treatment scans, but I think that needs to be rethought. Because I don't really know how beneficial post-treatment scans are in the decision making process. Not to say that we shouldn't do them or that we need to deviate from what we've been taught, but it's just an interesting thing to think about.
[Gopi Shah MD]
No, I think that's an important point you make up because you're right, not every... I feel like with sinus, there's not a straightforward algorithm for... You know what I mean? Certain things work better for others. And if the diagnosis itself is still in question, it makes sense to see what the scan looks like when their symptoms are present, because if the scan looks okay, then what are we really addressing?
[Ashleigh Halderman MD]
Yeah. And when you explain to patients that you're trying to... Especially with headaches, I like to use the analogy of you standing at a fork in the road, and on one side is sinus geared treatment and options, and the other hand is headache management. And so I'm trying to decide and make a really good decision as to what would be the best road to take, and what's going to provide them with the best relief because they've struggled for so long and they've been miserable and all I want is for them to feel better.
(5) Counseling for Patients with Unspecified Causes of Headache or Sinus Pain
[Gopi Shah MD]
Yeah. So I know we're talking about revision sinus surgery today, but for those patients, what is your management? Or what's the counseling like? And I think of it as the same thing as ear pain. Ear pain may not have an otologic reason or it may not be something that we find on an exam. Headaches a lot of times are not from sinus or something that we see on an ENT exam. How do you counsel those patients and how do you help them?
[Ashleigh Halderman MD]
Yeah. I use that analogy. And a lot of times I'll have them think back to all the things that they've done for their sinuses, and I'll ask them point blank, how effective was this ever? And sometimes come to this realization that not really. And I think that any patient just wants to feel like you are listening to them and that you're not trying to... I think headaches a lot of times people think you're trying to tell them that it's all in their head or something like that. And so I'll say, "Listen, I see a lot of patients who have for so long thought, my headaches are sinus related or sinusitis related."
And I'll always tell them, "Sinus headaches. So sometimes you get sinus headaches because you have swelling and infection in your sinuses, but other times you have sinus headaches because you have headaches and those headaches aren't being driven by a process that is within the sinus that I can fix with either medicines or surgery. So we need to determine what type of sinus headache you're having. And if you're having the kind of sinus headache that is related to inflammation and infection in the sinuses, I can continue to work in that realm. However, if there's just no evidence that we can find, and we think back to all the things you've done and all the surgeries that you've had and never made any difference, maybe it's time to start treating this like a headache. And I think we're going to have a lot more improvement in your symptoms and a better quality of life."
And some people are not very excited to hear that, but it's all into the delivery. You have to show the patient that you care and that you're not abandoning them and that you're not dismissing their symptoms or whatnot. And I'd say, I think that people appreciate that you're trying to get objective information, and I'll tell them that. When we get a CT scan and you're having these symptoms, I'm getting information that's very objective and is really going to clarify this picture for us. So I think eduCTion and letting them know that you're going to help them, even if it means that you're going to be sending them to a different doctor or it's going to be a different management plan than what you typically offer, you can have a very happy patient at the end of the day.
(6) Candidacy and Equipment Setup for Revision SInus Surgery Cases
[Gopi Shah MD]
I know. It makes a lot of sense. Well, I think let's get into the patients that do become candidates for revision sinus surgery. I would love to hear about your setup. But before we do that, do you use image guidance every time for these patients? Is there ever a time where you don't need to use image guidance in these patients?
[Ashleigh Halderman MD]
I'd say the one time I feel very comfortable not using image guidance is if I'm just revising the maxillary and maybe anterior ethmoids. But beyond that, I do recommend image guidance, because like I said before, forensic rhinology, there can be some significant alterations in the anatomy and you can also lose a lot of landmarks. And so it actually becomes very technically challenging. It can be a little confusing. So having anything that you can use at your disposal to help you and to guide you and to make it safer is never a bad idea.
[Ashley Agan MD]
And can you talk to us about your setup? What is on your back table, if you will and what do you make sure is on your mayo?
[Gopi Shah MD]
I always want my ball tip probe. What do you always like to make sure that is there?
[Ashleigh Halderman MD]
Oh, I love myself a double baller.
[Ashley Agan MD]
The ball tip seeker.
[Ashleigh Halderman MD]
Yeah, that's a classic one. Microdebrider, of course. I like the sickle knife for different things. I love myself the Hosemann that is probably the most beautiful, amazing instrument that humans could ever conceive. And it Thru-Cuts. And if there's a lot of osteitis then Kerrisons. But I tend to do my dissection more with the Microdebrider and Thru-Cuts. And when I'm using Thru-Cuts, actually, I like the PD sized instruments. I think that a lot of the regular size instruments are just enormous.
[Ashley Agan MD]
That's true.
[Ashleigh Halderman MD]
I like a more elegant dissection. PD Thru-Cut is probably one of my other favorite instruments.
(7) Operative Techniques and Considerations in Revision Sinus Surgery
[Ashley Agan MD]
And do you have a certain order that you tackle the surgery? Do you tend to go in the same order that you would when it's not a revision case or is it different?
[Ashleigh Halderman MD]
That depends entirely on the case. So if the anatomy is pretty identifiable and there are landmarks, and they're very clear, then I'm going to approach it in my typical manner, which is anterior to posterior and then once you get the sphenoid, you trace along the skull base coming posterior to anterior with an angled scope. But in cases where there are not a lot of landmarks, and I just had a case like this not too long ago, a patient with connective tissue disorder who had sinus surgery several times in a different country and the postoperative care was pretty sporadic. So they weren't doing debridements. And I don't even know that he was really rinsing and the amount of scarring that was present in the nasal cavities was just the worst I've ever seen and there were very, very few identifiable landmarks.
So in a case like that, the middle turbinate, I don't know, I think it was involved in a massive scar and I took a guess at what I thought it was. And as I dissected out, it became more clear. But in cases like that, I'll typically start by establishing the maxillary sinus and opening that up because that gives you a lot of detail. It gives you the roof of the maxillary sinus and it also gives you the posterior wall of the maxillary sinus. And the posterior wall of the maxillary sinus is roughly in the same depth as what your sphenoid face is going to be.
And then the height of the sphenoid os is going to be along the same line as the roof of your maxillary sinus. So I'll use my maxillary sinus to then establish where my sphenoid is. And then I will open the sphenoid really widely, because with the sphenoid I can determine where the lamina is and where the skull base is. And then you can use those two points to triangulate through when you're dissecting out the ethmoids. So that's where I'll do a bit of a different dissection.
[Gopi Shah MD]
And when you're doing... for example, there's uncinate left behind, or you have the enterostomy not connected to the natural os, what are you doing to make sure that all the uncinate's gone down or that your natural os is connected to the enterostomy? What are certain things that you go back either and check, or what are you doing to make sure those things are taken care of?
[Ashleigh Halderman MD]
So I like to use the ball tip seeker to hook behind any part of the residual uncinate, and gently use that to pull the uncinate off of the lamina and show myself that edge as to where that is. And I'll resect what I can of the uncinate. And then I'm going to use my 30 degree scope to really examine the middle meatus and the area of where I suspect the natural os is. And I think that that's a really critical step because in most patients you are not going to be able to see the natural os with a zero degree scope. It's parasagittal so you have to have that angle.
So I'm going to investigate the region with my zero degree scope, I'll probe around with the ball tip seeker, and try to fall into that space. And at the same time, I'm teasing to see, is there any residual uncinate left over? And if I find the os, make sure I join it up with the rest of the enterostomy. And then as you're moving more inferiorly, sometimes there is some uncinate still there but it's right at that junction of that and the maxillary line. So you're worried that if I take too many bites, I might injure the lacrimal system. And so I will take a backbiter and actually use that to palpate that edge right there. And if it moves, then I know that I do have a little bit more room, so I'll turn that down accordingly.
And that can be a little bit confusing in revision cases because even if they barely did anything to the uncinate, the bone can become very thick. And a lot of times you're making that move based on feel and you're stopping when the bone gets thick. So I think having excellent visualization and palpating make it more clear.
[Ashley Agan MD]
And what about the frontal recess or anterior ethmoid cells that have been left behind, any pearls for that region?
[Gopi Shah MD]
I just want to say, the anterior ethmoid cell is under-respected. I find the anterior ethmoids to be the more difficult parts of the case. And I feel like I never appreciated that until several years out practicing, but that's just my personal opinion. Sorry.
[Ashleigh Halderman MD]
Well, and I would go so far as to say, I think that we do a disservice of educating residents in general about the uncinate. I think that the message we send is that the uncinate is a bit of a throwaway part of the case, because, think about it, when you start out as a PGY-2, they're like, "Here, take down the uncinate. Get to the maxillary sinus." And I think that's actually technically way more challenging than taking down the bulla. So I've actually started residents out PGY-1s and 2s, I want to set them up for success. I want them to actually like sinus surgery. And what do you like? Well, you like what you feel like you're good at. And so I'm going to set them up for success and I'm going to...
I feel like I learned so much early on using angled scopes. That's just complicated. So I start them out with stuff that they can do with a zero degree scope and straight instruments. And actually I have a theory that an incomplete uncinectomy doesn't only lead to recirculation but it also leads to an incomplete ethmoidectomy and an incomplete frontal sinusotomy. So the superior part or the attachment of the uncinate, I tend to see people not be aggressive enough on that. And so as you're in the axilla of the middle turbinate, you really need to be aggressive in taking the uncinate up as high as you can. And I was taught by my fellowship director that you need to take the uncinate up until you can see the suprabullar recess. So there's a space above the bulla that you should be able to see once you've taken down your uncinate.
And the benefit of doing the complete uncinectomy and focusing on that spot is that it actually relaxes the middle turbinate quite a bit and it opens up your middle meatus even further. And so your turbinate drifts immediately more just naturally, and then you're typically able, if there's an agger nasi cell, you can see the inferior aspect of that agger nasi cell and you can see the suprabullar recess. So in doing this, you have defined the full height of your anterior ethmoid and you're going to do now a more complete dissection and not leave anything up above you. So that I think is a really critical point.
I'll start with identifying the bulla and obviously I try to resect that and its entirety. And then identify the basal lamella, go through the basal lamella. And if you're having a hard time identifying the level of the lamina, because there's typically more anterior ethmoid cells than there are posterior ethmoid cells. And the posterior ethmoid cells tend to be larger and more pneumatized. And I think we've all been in cases where there's tiny little air cells right on the lamina. So you think that you're on the lamina and you really don't want to go after these things, because the last thing anybody wants to see is orbital fat. And so you hedge off a little bit.
If you want to really establish the true level of your lamina, probably the safest place to do that is that first posterior ethmoid cell that you enter as you're taking down the basal lamella. Usually it's one big posterior ethmoid cell that air rates to the lamina. So if you just open that up and you get in there, you're going to be able to find the level of lamina a lot easier. And a quick mention about the basal lamella, I always make sure that I open up my basal lamella to expose the full width of my posterior ethmoid cavity. And what I mean by that is, I'm going to take it down laterally until I can see the orbit and I'm taking it immediately until I identify the superior turbinate.
[Gopi Shah MD]
Do you ever worry about destabilizing the middle turbinate too much with taking down too much of the basal lamella?
[Ashleigh Halderman MD]
It's a great question. And you sure can do that in some cases. But generally that's when you're taking the basal lamella down too far inferiorly. So that's where your strut is. So you want to make sure that you don't overdo it in that area. Usually if you're just going straight lateral and medial, you're not in strut territory. But I do think that in revision cases you find that the middle turbinate can be very demineralized and so it can disarticulate off it's attachment pretty easily.
[Gopi Shah MD]
And then going back to the frontal that super scarred down endoscopically, sometimes it's hard to tell what is what if everything's onion-skinned or layered up, you're not going to just follow up in it necessarily with a probe and you have to deal a bit more dissecting. And sometimes I find that the tissue itself like you said, can become osteitic or hard and it's on image guidance, you're like, "That's not skull base," but endoscopically, what you're feeling, it can almost make you feel like that. How do you get through those types of situations?
[Ashleigh Halderman MD]
Yeah. Revision frontals are super challenging for all the reasons that you just so well laid out. I think that the frontal, it starts with a really good review of your preoperative imaging. And I know that the International Frontal Anatomy Classification System came out not that long ago. And this is to take the place of the prior naming system, which was a little bit confusing at times. And it defines things more on an anatomic basis. So you have your agger cell, you have your super agger cell, which is the cell above the agger, but not pneumatizing into the frontal sinus. And then you have your super agger frontal cell, which is. And then you have your bulla, your suprabullar cell and your suprabullar frontal cell.
And so going through and very detailed understanding of the frontal recess anatomy in regards to those structures, I think is really key. And I like to evaluate my frontal recess with a sagittal CT scan. I think it gives you the best understanding, and this is where image guidance is really helpful. Obviously, you can only rely on it so far as it's accurate. So your understanding of the anatomy still is the most important tool in your toolbox. And I will look at the anatomy and try to identify each of those cells. And if I can, then I have a pretty good understanding of where I am and how the removal of this wall is going to open this next step up, so forth and so on. And what's important as well is, if you can identify these cells, then you should have a pretty good idea as to where your outflow tract is for your frontal. It's going to be posterior to your aggers, but anterior to your bulla cells. And so in between those, you should be able to find your frontal recess outflow tract.
(8) Special Considerations and Mistakes to Avoid Intra-operatively
[Ashley Agan MD]
So given these are revision surgery, you might be more worried about scarring afterwards. Do you feel like you are more inclined to use something like a steroid-eluting stent or maybe is that more for polyp patients or does it just depend?
[Ashleigh Halderman MD]
Really depends on the case. I'll say that I'm very picky about my middle turbinates. I tell the residents and I don't think this is hyperbole, that if you're middle turbinate lateralizes, you've just undone every single thing you've done in that surgery. I think that is just the worst... It's just like driving 500 miles to go to the beach and it's raining the entire time, you're there. This is just useless. So I do several things to make sure that my middle turbinate does not lateralize. So first I will bolgerize the turbinate, which is scratching the mucosa on the medial aspect of the turbinate. And then on the adjacent septum. I'll then pexy the turbinate to the septum with a quilting stitch. So I'll quilt a stitch through the septum with a Keith needle. And I start at the front of the nose. I do three passes on my way back. Third pass goes through the turbinates, through and through. And then I come forward through the septum, back to where I started and I tie the knot down.
Then I will place a spacer in the middle meatus. And we have Nasopore and so that's what I typically use. So very carefully, I will make sure that when I put my Nasopore in that I haven't stuck it on the wrong side of the turbinate. You got to make sure that you didn't detach your middle turbinate or snap that stitch with that. You have to make sure you get it into the middle meatus. And in some cases I will inject a little Kenalog into that Nasopore and if there's been a really bad frontal, if there was a lot of scar tissue or a lot of osteitic bone and I had to do drilling, then sometimes I'll put a little piece of Nasopore up there and inject that with some Kenalog.
And I really, really love Nasopore or anything that is in the middle meatus that is dissolvable. There's actually been a few studies where they did a single blinded study where they did bilateral sinus surgery, put a Nasopore in one side of the sinuses and not in the other, and the patient didn't know which was which. And they had them report their pain scores. Pain scores were actually lower on the side with the Nasopore in it. I think that's for a couple of reasons. Number one, I think it retains the moisture better when they're doing their rinses. And I think it prevents really hard crusts from forming. And those hard crusts are what patients find uncomfortable. And it also makes the first debridements that you do super straightforward and easy, which patients appreciate as well. Because they're going to be the most swollen at that time. They're going to be the most tender. And when you just are able to do that with a suction in a pretty quick fashion, it really goes over pretty well.
And I'll say that I counsel my patients on a couple of things, I'm a real stickler about. So number one, they have to do the rinses after surgery. And there's pretty good data out there that shows that not rinsing after sinus surgery increases the rate of ostial stenosis and scar formation and scarban formation and regular postoperative debridements lower that as well. So rinses and postoperative debridements, I believe are the two... I think first and foremost it starts with the surgeon's technique and your operative technique, but then afterwards rinses and debridements are going to keep things open and help the healing process.
[Gopi Shah MD]
Do you ever just take the middle turbinate and cut it in half? When are you just like, "This turbinate's got to go"? Is that blasphemy?
[Ashleigh Halderman MD]
No, not at all. There's actually some studies that show that it changes drug distribution and delivery into the sinuses. And there's some studies that show that if you resect it in polyp cases or whatnot and do a Lothrop on those people, then it decreases the number of revision cases.
I think where you have to be careful is this newly described central atopic disease, which is a lot of polypoid changes just on the middle turbinate and on the superior septum. The thing is, I've seen this in real life where a person removed a turbinate and then it seeds the entire sinus cavity. So that turbinate was actually acting as a protection. It was preventing all of those allergens from penetrating into the sinuses. And that polypoid change was evidence of that. But you remove that in central atopic people and bam, now it's like wildfire and they've got polyps everywhere.
And I think especially, revision cases where I see people removing the middle turbinate is as a way to avoid doing a septoplasty. And I definitely don't think that that's the right way to go about surgery. I love septoplasties. I think that they are beneficial on multiple levels. Obviously, Dr. Shah, you have different considerations to make operating in children. So this is in the adult population. But number one, if you're struggling at all, just do the darn septum, don't cut out the middle turbinate as a workaround, because it doesn't really help.
When you have a deviated septum, I think it probably alters the penetration of irrigations into the sinus cavities. It also makes it really uncomfortable for the patient when you try to scope them on that side. And in the end, you're just not going to get the view or the space to instrument that you're going to need to do actually really good sinus surgery. So septoplasty, thumbs up if needed.
[Ashley Agan MD]
Can you do any of this in the office or do you do any of this in the office? Let's say someone needs something where, I don't know, for example, maybe recirculation or something and you just need to connect that natural os. Do you ever do any of this in the office?
[Ashleigh Halderman MD]
Oh yeah. I absolutely have. It depends on the anatomy because sometimes it's very amenable. It also depends on the patient what they're able to tolerate and it depends on what else is going on and how extensive their disease is. Obviously, if it's just a single thing then yeah, absolutely will try to correct recirculation in the clinic. I also will drain some mucoceles in the clinic. If I have imaging and I can feel pretty comfortable and confident about it, then I will absolutely open up mucoceles.
(9) Post-Operative Pearls for Sinus Surgery Patients
[Ashley Agan MD]
As we are starting to wrap up, any final tips, tricks or pearls whether it's in the OR or your post-op care?
[Ashleigh Halderman MD]
Well, I said, regular debridements are crucial. And so I'll see a person for one week after surgery and clean out as much as I can. And then I'll see them a week or two after that. And that's really, really critical. I've also started putting patients on budesonide rinses in about the first or second postoperative appointment. Because I think it just helps with the healing, helps cut down some of that inflammatory reaction that you typically see in the sinuses after surgery. I mean, these are in non-polyp patients and polyp patients alike. And it avoids oral steroids, which is great and it just acts topically.
I don't do antibiotics for every patient after surgery. I'll see how they're doing and if I see some gunky look and stuff, I'll give them doxycycline but only if I see that. And if they're not rinsing, you can tell and I'll have a very frank conversation with them about that. And then usually I'll arrange a shorter term follow up to make sure that things are heading in the right direction.
But I think key takeaways, number one, make sure the right diagnosis was made. Number two, make sure that you understand the anatomy to the best of your ability after reviewing your imaging in great detail. Number three, utilize the best technique possible as you're doing the surgery itself. And by that, I mean a complete surgery with removal of all the ethmoid partitions, identifying the lamina and the skull base and preserving mucosa and that's a huge one. You strip the mucosa and that is going to always be a problem area. And then regular care and follow up with rinses and debridements is absolutely crucial. So I think those are the main highlights as far as how to be successful with revision cases.
[Ashley Agan MD]
Well, thank you so much for taking the time. We covered a lot of information. It could probably go on longer if we had the time, but we appreciate you being here, giving us the rundown for our listeners.
[Ashleigh Halderman MD]
Of course. Ladies, thanks so much for having me.
[Gopi Shah MD]
Thank you, Ash.
[Ashleigh Halderman MD]
I miss you girls.
[Gopi Shah MD]
I know.
[Ashleigh Halderman MD]
Hi friends. Again, no, thank you so much for having me. I love that you're doing this and just mad respect to the two of you and I'm really, really grateful for this opportunity.
[Gopi Shah MD]
Well, thank you so much again, Ash, and thank you for letting me call you all the time and get your advice on some of my own sinus cases. I really appreciate your guidance.
[Ashleigh Halderman MD]
Oh, girl, anytime. I like to talk boogers.
[Gopi Shah MD]
So thank you to all of our listeners. If it's your first time, thank you for stopping by. If you are coming back on and listening, we really appreciate your time and support. You can find us on SoundCloud, Spotify, iTunes, Apple, and Gaana. Please follow us on Instagram and Twitter @_backtableent. We love feedback. Reach out to us for topics, ideas, speakers, or if you ever want to come on the show. Thank you to our audio engineer today, Kieran Gannon and our blog writers Wasiq Nadeem and Varun Sagi. And of course our media MVP’s, Chi Dang and Anh Dang, they're twin sisters and they're amazing. And I think that's a wrap. Thank you for tuning in.
Podcast Contributors
Dr. Ashleigh Halderman
Dr. Ashleigh Halderman is an Assistant Professor and practicing ENT specializing in rhinology and skull base surgery in the Department of Otolaryngology at UT Southwestern in Texas.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 31). Ep. 30 – Revision Endoscopic Sinus Surgery [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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