Revision Sinus Surgery

moving the incision to the immediate vicinity of an isolated septal deflection (Fig. 11.2).

■The ability to minimize mucosal elevation is a particular advantage in revision septoplasty, where adherent flaps from prior submucous resection may be difficult to dissect.

Furthermore, simultaneous endonasal endoscopic examination allows the surgeon to gauge the progress made toward achieving relief of nasal obstruction and adequate

surgical exposure. Finally, the endoscopic approach provides an excellent teaching tool. Demonstration of surgical anatomy and technique on the video monitor provides an invaluable learning opportunity for students, residents, and surgical assistants.

The patient is positioned, prepared, and draped for septoplasty as is standard for endoscopic sinus surgery. Topical oxymetazoline is applied for decongestion and 1% lidocaine with 1:100,000 epinephrine injected sub­ perichondrially.

Fig. 11.2  Limited endoscopic septoplasty for isolated septal deflection. a Posteriorly placed incision just anterior to septal deviation. b–c Elevation of the mucoperichondrial flap and ex-

cision of the deviated cartilage and bone. d Reapposition of the mucosal flap and confirmation of adequacy of resection

■The incision is typically placed on the ipsilateral side of maximal deviation.

■For a broadly deviated septum, a standard hemi-trans- fixion incision is used.

■For more posterior isolated deformities or in revision septoplasty, a more posteriorly placed incision in the immediate vicinity of the deformity can be made with an angled scalpel blade.

Surgical Technique Principles

■Once the plane of dissection is established, the mucoperichondrial flaps are elevated with a suction Freer or Gorney elevator under direct endoscopic visualization.

■A scope irrigator can greatly enhance visualization while working beneath the septal flaps.

■After complete elevation of the ipsilateral septal flap, the septal cartilage is incised at the point of maximal deflection, and the contralateral flap elevated.

■Flap elevation is continued bilaterally until the complete extent of septal deformity has been dissected.

■The deviated septum is then excised using standard septoplasty instruments as well as endoscopic scissors, punches, or forceps.

■The adequacy of the septoplasty is confirmed by performing serial endoscopy of the nasal cavity.

■Closure involves reapposition of the septal flaps, followed by a running quilting stitch, which is placed endoscopically with a 4–0 plain gut suture on a Keith needle.

■When a hemi-transfixion incision has been made, the incision is closed under direct visualization with a 5–0 plain gut suture.

■When the incision has been placed posteriorly for limited septal work, no closure of the incision is required.

■No nasal packing is required.

The endoscopic septoplasty technique is also useful for removing isolated septal spurs. A longitudinal incision is made along the apex of the spur and mucosal flaps are then elevated above and below the spur to reveal the spur and allow its removal. The superior and inferior flaps can be then be reapproximated and the incision usually does not need to be closed with suture. This approach minimizes the degree of flap dissection and reduces the risk of flap perforation.

Refractory chronic sinus disease is not typically due to inferior turbinate hypertrophy. However, symptoms of nasal obstruction are common among patients with significant sinonasal inflammation, and therefore inferiorturbinate reduction should be considered in the revision FESS candidate with turbinate hypertrophy and obstructive symptoms.

■The goal of inferior turbinate reduction is to provide a controlled reduction of the inferior turbinate soft tissue with maximal mucosal preservation.

Several different techniques are currently available for inferior turbinate soft-tissue reduction including laser, radiofrequency, and microdebrider submucous resection. The authors prefer the use of powered instrumentation for submucous resection of the inferior turbinates and believe that it offers several advantages.

Advantages of Microdebrider

Inferior-Turbinate Reduction

■Microdebrider reduction is clinically efficacious while offering excellent mucosal preservation.

■The surgeon can sculpt targeted anatomic regions of the inferior turbinate that may not be as well approached with other techniques, including the su- perior–anterior and most inferior aspect of the turbinate.

■Finally, while thermal reduction techniques depend on the contracture of turbinate tissue that occurs over time as necrosed regions are replaced by fibroblasts, the results with microdebrider reduction are immediate.

The procedure can be performed in either the office or the operating room setting. A total of 1–2 ml of 1% lidocaine with 1:100,000 epinephrine solution is injected in the anterior aspect of the inferior turbinate. An incision at the anteriormost aspect of the inferior turbinate is made just behind the mucocutaneous border. The incision can be made with a number 15 scalpel or with a specially designed turbinate microdebrider blade with a built-in dissector (Medtronic, Jacksonville, Florida, USA). A submucoperiosteal flap is elevated along the anterior half of the inferior turbinate. The turbinate blade is then placed facing outward to reduce the soft tissue under endoscopic visualization via serial passes of the blade from posterior to anterior. The reduction in size of the inferior turbinate is usually recognized immediately as the procedure progresses. Out-fracture of the inferior turbinate using

a Boies elevator is frequently performed concurrently as a complementary procedure. Hemostasis is typically achieved with topical epinephrine, and packing is very rarely required. The incision need not be closed.

Excision of Middle-Turbinate Concha Bullosa

■Surgical resection of a concha bullosa entails careful preservation of the medial lamella (which attaches to

the skull base) and resection of only the lateral half of the turbinate (Fig. 11.3).

The extent of middle-turbinate pneumatization is evaluated on CT scans and allows the surgeon to anticipate points of safe entry into the lumen of the concha bullosa. Local anesthetic is injected as is routine for FESS, including the middle turbinate mucosa. The concha bullosa is then entered with sharp dissection using either a sickle knife or sharp Freer elevator. Because the lumen of the

Fig. 11.3  Surgical resection of the concha bullosa. a The concha bullosa is entered sharply with a sickle knife. b The incision is extended superiorly and inferiorly with endoscopic scissors.

c The lateral aspect of concha bullosa is resected with throughcutting forceps. d The medial lamella mucosa and attachment to the cribriform plate are preserved

concha bullosa is a functional ethmoid air cell, great care must be taken to enter the turbinate without disrupting the mucosal lining of the interior of the concha bullosa. Once proper entry is confirmed by endoscopic visualization, the incision is extended from superior to inferior with either endoscopic scissors or sickle knife, taking care to not destabilize the attachment of the medial lamella to the cribriform plate. Turbinate scissors and through-cut- ting forceps are then used to continue dissection posteriorly. Removal of the lateral lamella may be performed with a microdebrider or in a piecemeal fashion with through-cutting forceps. In certain cases, the pneumatized middle turbinate may be approached from the posterior free edge of the lateral lamella; dissection in these situations can proceed from posterior to anterior using a back biter forceps.

In the revision surgical approach to the partially resected concha bullosa, care should be taken to ensure that all areas of pneumatization have been addressed. Inadequate resection of the inferior bulbous portion of the middle turbinate can result in narrowing of the middle meatus, while incomplete resection of the pneumatized vertical lamella of the pneumatized turbinate can narrow the ethmoid cavity and frontal recess.

Lateralized Middle-Turbinate Release

Lateralization of the middle turbinate is a common finding in the post-FESS patient and may occur as a result of several factors. First, the turbinate may be attenuated and “floppy” due to over resection. Secondly, surgical trauma to the mucosal surface of the turbinate may predispose to the development of adhesions with the lateral nasal wall. Thirdly, inadequate postoperative debridement may allow early granulation to mature into adherent synechiae. Because middle-turbinate lateralization may collapse, scar, and narrow the sinus outflow tracts, surgical correction is often indicated in the revision FESS patient.

The patient is positioned, prepared, and draped as is standard for endoscopic sinus surgery. Topical oxymetazoline or epinephrine (1:1000) is applied preoperatively for decongestion. Intraoperative surgical navigation may be helpful during the initial diagnostic endoscopy, confirming the relationship of the middle-turbinate remnant to the medial orbital wall. The position of the skull base and cribriform plate should also be determined. Once these critical anatomic structures are delineated, safe infiltration of the middle-turbinate remnant and medial orbital wall with 1% lidocaine with 1:100,000 epinephrine solution is performed.

The initial step is a release of the scarred middle turbinate from the lateral nasal wall. The release is achieved through a vertically oriented incision between the tur-

binate remnant and the lateral nasal wall, parallel to the medial orbital wall. The synechiae can be divided with endoscopic scissors or a small through-cutting instrument, such as a pediatric Blakesley forceps (Fig. 11.4). Once the turbinate has been released from its lateral scarred position, the degree of previous middle-turbinate resection can be more fully assessed. When previous middle-turbi- nate resection has been limited, releasing the lateralized turbinate will reveal a near-normal appearing middleturbinate remnant.

■The goal in cases with middle-turbinate lateralization is to allow the middle turbinate to heal in a medial position.

This can be achieved by placement of a middle meatal stent for approximately 7 days. Optional scarification of the middle turbinate to the nasal septum can be performed concurrently by abrading the apposing surfaces of the middle turbinate and adjacent septum; middle meatal stenting will bring these surfaces together to facilitate a favorable adhesion. Alternatively, suturing of the middle turbinate to the septum is an effective method of turbinate medialization. A simple dissolvable mattress suture (4–0 plain gut on a straight Keith needle) placed endoscopically will allow sufficient time for the medialized turbinate to heal without reforming adhesions to the lateral nasal wall.

If the middle-turbinate remnant is substantially truncated or ossified from prior resection, restoration of the turbinate to a medial position may not be possible. In such cases, selective resection of the lateralized portions of the turbinate may actually be necessary to relieve ethmoid or frontal obstruction.

Regardless of the surgical strategy employed, postoperative inspection and debridement of granulation is important to prevent early scar formation and relateralization.

Superior-Turbinate Resection

Although less common, revision surgery involving the superior turbinate can pose similar challenges to those posed by the middle turbinate. Just as the middle turbinate forms the medial border of the anterior ethmoid cavity, the superior turbinate defines the medial border of the posterior ethmoid cavity. As imprecise anterior ethmoid and frontal recess dissection can lead to destabilization and scarring of the middle turbinate, so too can posterior ethmoid and sphenoid surgery lead to superior-turbinate scarring and postsurgical failure.

When sphenoidotomy is performed through a transethmoidectomy approach, the inferior portion of the

11

superior turbinate is resected with a through-cutting instrument to expose the natural sphenoid ostium within the sphenoethmoid recess. Once identified, the sphenoid ostium is enlarged and the anterior wall of the sinus removed using through-cutting punches and forceps. In situations where the inferior portion of the superior turbinate is not resected cleanly, the remnant superior turbinate may form adhesions with adjacent tissue. The sphenoid outflow may then be compromised because either the natural ostium is obstructed or recirculation of mucous has developed around the superior turbinate between the natural ostium and surgical sphenoidotomy.

Surgical correction of a scarred superior turbinate is relatively straightforward. The first step is to identify and cannulate the natural ostium of the sphenoid sinus. At this point, resection of the scarred inferior aspect of the

Fig. 11.4  Release of the lateralized middle turbinate. a Previous resection of the middle turbinate with lateralization and scarring to the lateral nasal wall. b Dense scar tissue between the middle-turbinate remnant and medial orbital wall. c Vertically oriented release of synechiae and medialization of the middle-turbinate remnant

superior turbinate should be performed with a throughcutting forceps. The sphenoid ostium can then be enlarged and brought into continuity with the remainder of the surgical sphenoidotomy, as necessary.

■Conservative resection of the inferior third of the superior turbinate should not result in significant disturbance of the olfactory neuroepithelium.

Tips and Pearls to Avoid Complications

1.Palpate the septum carefully in revision septoplasty in order to anticipate the extent of prior submucous resection. Take extra caution in elevating the mucosal flaps over absent septal bone or

cartilage, or move the incision posteriorly to avoid dissecting in areas of prior surgery.

2.If possible, minimize dissection of the posterior third of the inferior turbinate during soft-tissue reduction. This area may carry feeding vessels from the sphenopalatine artery and may be more prone to postoperative bleeding.

3.Always confine concha bullosa excision to the lateral aspect of the turbinate. The medial turbinate carries the attachment to the skull base and should be left undisturbed.

4.Be aware of the presence of middle-turbinate lamellar cells, which can harbor disease and should be opened along with pneumatized portions of the bulbous middle turbinate.

References

6.Elahi MM, Frenkiel S, Fageeh N (1997) Paraseptal structural changes and chronic sinus disease in relation to the deviated septum. J Otolaryngol 26:236–240

7.Hwang PH, McLaughlin RB, Lanza DC, et al (1999) Endoscopic septoplasty: indications, technique, and results. Otolaryngol Head Neck Surg 120:678–682

8.Lanza DC, Kennedy DW, Zinreich SJ (1991) Nasal endoscopy and its surgical application. In: Lee KJ (ed) Essential Otolaryngology: Head and Neck Surgery, 5th edn. Medical Examination, New York, pp. 373–387

9.Musy PY, Kountakis SE (2004) Anatomic findings in patients undergoing revision endoscopic sinus surgery. Am J Otolaryngol 25:418–422

10.Senior BA, Kennedy DW, et al (1998) Long-term results of functional endoscopic sinus surgery. Laryngoscope 108:151–157

11.Stallman JS, Lobo JN, Som PM (2004) The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. Am J Neuroradiol 25:1613–1618

nus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 101:56–64

2.Calhoun KH, Waggenspack GA, Simpson CB, et al (1991) CT evaluation of the paranasal sinuses in symptomatic and asymptomatic populations. Otolaryngol Head Neck Surg 104:480–483

3.Cantrell H (1997) Limited septoplasty for endoscopic sinus surgery. Otolaryngol Head Neck Surg 116:272–276

4.Chu CT, Lebowitz RA, Jacobs JB (1997) An analysis of sites of disease in revision endoscopic sinus surgery. Am J Rhinol 11:287–291

5.Chung BJ, Batra PS, Citardi MJ, et al (2007) Endoscopic septoplasty: revisitation of the technique, indications, and outcomes. Am J Rhinol 21:307–311

gery. Decker, Philadelphia

13.Ulusoy B, Arbag H, Sari O, et al (2007) Evaluation of the effects of nasal septal deviation and its surgery on nasal mucociliary clearance in both nasal cavities. Am J Rhinol 21:180–183

14.Uslu H, Uslu C, Varoglu E, et al (2004) Effects of septoplasty and septal deviation on nasal mucociliary clearance. Int J Clin Pract 58:1108–1111

15.van Alyea OE (1939) Ethmoid labyrinth. Arch Otolaryngol 29:881–902

16.Yasan H, Dögru H, Baykal B, et al (2005) What is the relationship between chronic sinus disease and isolated nasal septal deviation? Otolaryngol Head Neck Surg 133:190–193

17.Zuckerkandl E (1882) Normale und pathologische Anatomie der Nasenhöhle und ihrer pneumatischen Anhänge. Wilhelm Braumüller, Wien

 Core Messages

■Revision FESS is substantially more complex than primary surgery due several factors.

■Etiologies for recalcitrant postsurgical chronic rhinosinusitis are classified broadly as environmental, host, or iatrogenic.

■In order to maximize the success rate of revision FESS the surgeon must be familiar with the evaluation, diagnosis, surgical anatomy, and management of these complex patients.

Introduction

Causes for Surgical Failures

Functional endoscopic sinus surgery (FESS) is indicated for the treatment of symptoms of chronic rhinosinusitis (CRS). Success rates after FESS have been reported as ranging from 74 to 97.5% [13, 14, 22], leaving 2.5–26% of patients still suffering from persistent symptoms and signs of chronic infectious and/or inflammatory sinus disease following surgery. As more and more primary FESS procedures are performed, the number of patients who are being evaluated for revision sinus surgery is also increasing. This chapter will help to educate the otolaryngologist about patients who present with failure of primary maxillary and ethmoid sinus surgery, whether due to inadequacy of the primary surgery or the recurrence of sinonasal mucosal disease resulting from underlying medical or immunologic conditions. The chapter will also provide a guideline for the diagnosis, management, and treatment of patients presenting with persistent symptoms of CRS after sinus surgery.

Causes of treatment failures following FESS include environmental factors, host systemic diseases, iatrogenic problems, and surgical deficiencies [6]. Taken as a whole these are thought to impair normal mucociliary clearance and cause postoperative surgical treatment failures. Environmental control is an important component in the medical management of patients with CRS; exposure to irritants and allergens should be minimized or eliminated whenever possible [6].

Similarly, host systemic diseases may cause excessive mucosal inflammation and result in further impairment of mucociliary clearance. These conditions include allergic diathesis [14], the recurrent sinonasal polyposis that can result from the inflammatory response seen in Churg Strauss Syndrome or Job’s Syndrome, cystic fibrosis [19], granulomatous disease, neoplasia, and immotile ciliary syndrome [1]. Some authors propose that the presence of eosinophilic infiltration, as seen in both allergic and nonallergic rhinosinusitis, can be an important variant in predisposing a patient to the closure of a middle meatal antrostomy with subsequent persistence of inflammatory

changes within the maxillary sinus [8, 10]. Similarly, in patients with sinonasal polyposis, a history of previous sinus surgery, asthma, or allergy predicted recurrence and need for revision surgery [23].

Iatrogenic causes of treatment failure can result from poor surgical technique (i.e., an improperly placed maxillary antrostomy), middle-turbinate resection with lateralization of the turbinate remnant, inadequate postoperative nasal debridement, or deficient postoperative medical management leading to a persistent infectious or inflammatory mucosal response. Furthermore, overaggressive removal of healthy mucosa resulting in bone exposure during primary FESS or, alternatively, failure to remove diseased bony ethmoid partitions may lead to significant scarring or an osteitic response.

A suggested important reason for surgical failure is a “missed ostium sequence” [21]:

■Inadequate surgical removal of the most anterior portion of the uncinate process blocks visibility of the most anterior fontanelle leading to failure to identify

the natural maxillary ostium and incorporate it in the 12 maxillary sinus antrostomy. An accessory maxillary ostium may be mistakenly enlarged resulting in persistent disease due to mucociliary flow being directed toward the obstructed natural outflow tract rather

than toward the surgically created antrostomy.

■Surgical antrostomies that do not communicate with the natural ostia can also generate a “recirculation phenomenon” in which mucus is swept by the cilia out of the maxillary sinus via the natural ostium but then reenters the sinus though the improperly placed surgical antrostomy (Fig. 12.1) [21]. This may lead to persistence of maxillary sinus disease.

Surgical trauma to the nasal mucosa, associated with mucosal stripping and bone exposure, can often result in synechiae, fibrosis, regrowth of poorly ciliated epithelium, osteoneogenesis, and osteitis (Fig. 12.2), which have all been implicated as potential etiologies of surgical failure [21]. Bacterial invasion of exposed bone and the subsequent chronic inflammatory reaction are thought to potentiate the osteoneogenesis process. Inflammation within the bone is difficult to eradicate and can be a nidus for local production of additional inflammatory mediators causing persistent mucosal disease and inhibition of healing [6]. In addition, mucosal stripping and the creation of raw surfaces may result in postoperative lateralization of the middle turbinate and subsequent synechiae formation adhering the middle turbinate to the lateral nasal wall (Fig. 12.3). Secondary anatomic obstruction of the ostiomeatal pathways often results.

Ramadan reviewed 398 patients who did not have a medical history of immunodeficiency, systemic disorders, cystic fibrosis, or ciliary abnormality, but whose

Fig. 12.3  Lateralized middle turbinate. Endoscopic visualization (0 endoscope) of a lateralized right middle turbinate (asterisk). A web of scar tissue (yellow arrow) has formed between the middle turbinate (asterisk) and the lateral nasal wall (red arrowheads), thus leading the lateralization of the middle turbinate and persistence of chronic rhinosinusitis after primary FESS

Fig. 12.2  Osteitis. Preoperative coronal computed tomography (CT) scan or the paranasal sinuses in a patient undergoing revision FESS. Areas of osteitic bone within the ethmoid cavity (yellow arrows), retained uncinate process (white arrows) leading to scarring of the maxillary antrostomy, and an undissected concha bullosa (white asterisk) have likely contributed to this patients primary FESS failure

CRS symptoms persisted after their primary FESS procedure. Fifty-two of these patients required a revision FESS procedure. He found that the revision cases had a higher mean computed tomography (CT) score, according to the Lund-MacKay staging system, compared with nonrevision cases. Fifty six percent of the revision cases had evidence of adhesions, and the most common cause of revision surgery was the presence of residual air cells and stenosis of sinus ostia [22] . Chambers et al. and Hinohira et al. noted that scarring in the middle meatus, residual ethmoid cells, and stenosis of the maxillary sinus ostium are the common causes for surgical failure [4, 12]. Chu et al. reported 153 patients requiring revision sinus surgery and found that the most common surgical alteration to be partial middle turbinectomy with resulting lateralization of the middle turbinate remnant and subsequent scarring of the middle meatus [5]. Thus, mucosal preservation during both primary and revision FESS is essential for a successful outcome. This can be achieved with use of through-cutting instruments and directed powered mucosal shaving techniques.

Incomplete surgery resulting in persistent symptoms following primary FESS may be due residual ethmoid air cells or the failure to address anatomic findings such as pneumatization of the middle turbinate (concha bul-

losa), deviation of the nasal septum, and the presence of infraorbital (Haller) cells [3, 20]. In a study by Musy and Kountakis, among 70 patients with primary surgical failure, 70% had a lateralized middle turbinate and 64% had an incomplete anterior ethmoidectomy [17]. A retained foreign body (e.g., infected dental implant in the maxillary cavity) can also cause persistent sinonasal infection and disease.

Preoperative Workup and Indications

Evaluation for revision sinus surgery begins with the patient’s history, including a thorough review of the past medical history, as well as the physical exam. Potential environmental and host factor influences are carefully discussed. Close attention is paid to eliciting a history of immunodeficiency, cystic fibrosis, granulomatous and autoimmune disease, and genetic syndromes, such as Kartagener’s syndrome and Churg Strauss Syndrome. The surgeon should also obtain original records and radiographs whenever possible. Prior surgical technique, peri-

12 operative medical therapy as well as a schedule of postoperative surgical debridements should to be reviewed. It is prudent to know whether a mucosal-preserving technique was used, appropriate antibiotics and steroid treatments prescribed, adequate and timely debridement procedures performed, and whether the patient had used sterile nasal saline irrigation and/or any other alternative therapies that may have complicated treatment [6].

Nasal endoscopic evaluation of the patient is also of utmost importance. The degree of inflammation and/or infection of the sinuses can be assessed. Moreover, most surgically created anatomic problems can be identified: retained uncinate process, scaring and synechiae formation, lateralized middle-turbinate remnants, improperly placed maxillary antrostomy, or residual infraorbital cells [6]. The mucosal findings are potentially reversible, especially if not associated with anatomic obstruction. The patient’s symptoms can often be correlated with the endoscopic findings and therefore should be carefully documented. The revision surgeon should be convinced of the rhinologic origin of the patient’s symptoms before planning surgery.

Preoperative identification and treatment of a resistant bacterial infection can aid in revision surgery. Staphylococcus aureus, methicillin-resistant S. aureus, and Gramnegative organisms, such as Pseudomonas, are the most common bacteria in patients presenting for revision surgery [2, 18]. Purulent secretions should be cultured and culture-directed antibiotics initiated prior to surgery. Therapy in patients suffering from allergic fungal sinusitis or eosinophilic mucin rhinosinusitis may include systemic and topical antifungals and steroids [9].

The majority of the patients are treated with topical

steroid therapy as well as systemic antibiotic and steroid therapy as part of the initial medical management of their recurrent sinus disease. Many otolaryngologists advocate a short burst of high-dose oral steroids just prior to revision surgery, in order to reduce sinonasal mucosal edema and facilitate the delineation of anatomic structures. Preoperative steroids, 20–40 mg/day for 4–10 days can reduce polyp size, stabilize or reduce mucosal edema, and reduce intraoperative bleeding [6].

A recent CT scan of the paranasal sinuses is required after maximal medical therapy. In the case of revision maxillary and ethmoid sinus surgery, close attention should be paid to evaluation of the residual uncinate process, residual ethmoid cells and septae, supraorbital ethmoid cells, infraorbital ethmoid cells, and the presence of mucoceles. It is imperative to evaluate the skull base height (Keros I–III) and position of the lamina papyracea, as well as to check for evidence of previous breach of these boundaries. An example of a residual uncinate process seen on coronal CT of the sinuses is shown in Fig. 12.4.

Magnetic resonance imaging (MRI) can be a useful adjunct radiologic modality in the evaluation of patients with skull-base dehiscence, previous orbital injury, or in cases of sinonasal neoplasia. MRI can identify the presence of a meningoencephalocele, help distinguish between tumor, polyps, mucin, and secretions, and assess the integrity of the periorbita and dura.

Fig. 12.4  Retained uncinate. Preoperative coronal CT scan of the paranasal sinuses in a patient undergoing bilateral revision endoscopic maxillary antrostomy. Fragments of retained uncinate process (yellow arrows) lead to scarring and eventual stenosis of the maxillary antrostomy bilaterally. As a result, the patient suffered from chronic maxillary rhinosinusitis after primary FESS