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30.Shirazi MA, Silver AL, Stankiewicz JA (2007) Surgical outcomes following the endoscopic modified Lothrop procedure. Laryngoscope 117:765–769

31.Sonnenburg RE, Senior BA (2004) Revision endoscopic frontal sinus surgery. Curr Opin Otolaryngol Head Neck Surg 12:49–52

32.Stammberger H, Posawetz W (1990) Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 247:63–76

33.Tran KN, Beule AG, Singal D, Wormald PJ (2007) Frontal ostium restenosis after the endoscopic modified Lothrop procedure. Laryngoscope 117:1457–1462

34.Weber R, Draf W, Keerl R, Kahle G, Schinzel S, Thomann S, Lawson W (2000) Osteoplastic frontal sinus surgery with fat obliteration: technique and long-term results using magnetic resonance imaging in 82 operations. Laryngoscope 110:1037–1044

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35.Weber R, Draf W, Keerl R, Schick B, Saha A (1997) Endonasal microendoscopic pansinus operation in chronic sinusitis. II. Results and complications. Am J Otolaryngol 18:247–253

36.Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD (2001) Modern concepts of frontal sinus surgery. Laryngoscope 111:137–146

37.Weber R, Hochapfel F, Draf W (2000) Packing and stents in endonasal surgery. Rhinology 38:49–62

38.Weber R, Mai R, Hosemann W, Draf W, Toffel P (2000) The success of 6-month stenting in endonasal frontal sinus surgery. Ear Nose Throat J 79:930–932, 934, 937–938

39.Wormald PJ (2003) Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure. Laryngoscope 113:276–283

40.Wormald PJ, Ananda A, Nair S (2003) Modified endoscopic Lothrop as a salvage for the failed osteoplastic flap with obliteration. Laryngoscope 113:1988–1992

 Core Messages

■Revision endoscopic frontal sinus surgery is a challenging procedure that should be undertaken only by the experienced sinus surgeon.

■Evaluation and understanding of the frontonasal outflow tract in the setting of previously surgically altered anatomy is essential.

■Choice of procedure for the revision frontal sinus surgery depends not only on careful preoperative evaluation of available computed tomography radiography, but also on the underlying pathology.

■Careful postoperative debridement and monitoring is essential for the success of any revision frontal sinus operation.

Introduction

Revision endoscopic frontal sinus surgery remains one of the greatest challenges facing the skilled endoscopic surgeon. Primary endoscopic sinus surgery has a long-term success rate greater than 90%; therefore, patients requiring revision frontal sinus surgery represent a subset of patients with advanced or poorly controlled disease. To increase the chance of success, the endoscopic surgeon should reevaluate the underlying cause of the patient’s symptoms. If they are attributable to frontal sinus pathology, then a thorough evaluation should be performed as to the cause underlying failure of the previous operation. The patient’s surgical anatomy should be properly reevaluated and the surgeon should be prepared for altered and unusual findings, such as missing and/or distorted landmarks, missing bone, prolapsed orbital contents, encephaloceles, and tumors. A proper revision procedure should be selected and performed by an endoscopic surgeon skilled in this approach, using advanced technology

such as computerized image guidance and advanced frontal sinus instrumentation when appropriate. Finally, medical management directed at the patient’s underlying pathophysiology, meticulous postoperative debridement, and comprehensive patient education will improve the likelihood of success in this often difficult to manage subset of sinus patients.

Patient Selection/Preoperative Evaluation

Prior to consideration for any revision endoscopic procedure, a thorough reevaluation should be carried out for each patient by performing a comprehensive history and physical examination with angled rigid and/or flexible endoscopy. Initially, a reevaluation should be made as to whether a patient’s signs and symptoms are attributable to chronic frontal sinusitis.

Tips and Pearls

1.Primary complaints of headache, while more common with frontal sinusitis, are poor predictors of surgically amenable sinus disease.

2.Evaluation for migraines and other causes of headaches by a qualified neurologist should be pursued with a very low threshold for patients with headache and absent rhinosinusitis symptoms.

Similarly, evaluation for allergic, rheumatologic, psychiatric, and other causes of a patient’s symptomatology should always be considered. A review of previous records including previous radiology and pathology reports should be performed whenever possible and will be helpful in ascertaining the true nature of the patient’s disease.

Chronic mucosal diseases such as aspirin-induced asthma (Samter’s triad), cystic fibrosis, ciliary dysmotility, allergic fungal rhinosinusitis, chronic eosinophilic hyperplastic sinusitis, and others increase the likelihood that the patient’s symptoms are attributable to recurrent frontal sinusitis. A comprehensive physical examination will allow the sinus surgeon to detect possible systemic manifestations of an underlying disease that may reveal the true diagnosis for a patient. Angled rigid sinonasal endoscopy and flexible endoscopy (often performed consecutively) are helpful in evaluating the frontal sinus outflow tract and may alert the sinus surgeon to subtle mucosal disease

15 and iatrogenic findings. Photodocumentation of endoscopic findings should be utilized whenever possible.

Repeat radiographic imaging is essential for analyzing the diseased frontal sinus. High-resolution computed tomography (CT) analyzed in the coronal, axial, and sagittal planes will allow the surgeon to gain an understanding of the altered three-dimensional anatomy of the frontal sinus and frontal sinus outflow tract. Postoperative films should be compared to preoperative films whenever possible. Magnetic resonance imaging should be supplemented when necessary, as it allows the surgeon to gain a better understanding of the soft-tissue anatomy of a previously operated frontal sinus. This includes distinguishing mucoceles versus encephaloceles, identifying defects in the lamina with periorbital fat herniation, and alerting the sinus surgeon to possible tumors such as inverting papillomas and other rare benign and malignant sinus and skull-base tumors.

Preoperative Assessment/Planning

If the patient’s disease is attributable to chronic frontal sinus pathology, then a thorough analysis for the failure of previous frontal sinus surgery should be performed. Broadly, causes for frontal sinus disease in the setting

of previous frontal sinus surgery can represent lack of optimal medical management, persistent disease due to incomplete surgery, iatrogenic disease, and recurrent disease following a successful procedure.

Prior to consideration of any repeat surgical procedure, the rhinologist should ascertain the previous medical management of the patient’s disease and, in particular, their compliance to these regimens. Nasal saline irrigations, culture-directed oral and intranasal antimicrobial drugs, intranasal steroid sprays and irrigations, mucolytics, and oral anti-inflammatory agents such as leukotriene inhibitors and oral steroids have all been used with varying efficacy in controlling chronic frontal rhinosinusitis. Often, patients with poor outcomes following initial surgery have a poor history of compliance to medical regimens. Time spent in the office educating patients on the necessity and proper techniques of medical management may obviate the need for further operations.

■The best likelihood of success with a repeat operation is in the setting of persistent disease due to a previous incomplete or inadequate surgery.

The quality of previous surgery in the setting of persistent disease varies significantly, with some patients having minimal prior frontal recess surgery being performed and some patients having extensive frontal recess surgery, with the critical obstruction of the frontal sinus still remaining. Reviewing CT scans in multiple planes is very helpful, and sagittal reconstructions are now available on most imageguidance workstations and advanced image viewers.

■The most common causes of persistent frontal sinus obstruction are obstruction from a remnant agger nasi cell and a medially displaced superior remnant of the uncinate process (Fig. 15.1).

Fig. 15.1  Agger nasi obstructing the frontal sinus outflow tract

Often, a remnant cap of an ethmoid bulla (mistaken to be the true frontonasal outflow tract) is the cause of persistent frontal sinus outflow obstruction. This is particularly common when angled endoscopes were not used in prior surgeries, as a 45 and often only a 70 endoscope allow visualization of the roof of the frontal sinus.

Tips and Pearls

Common causes of persistent frontal sinus disease:

1.Remnant Agger nasi.

2.Remnant cap of ethmoid bulla.

3.Retained frontal cells.

4.Retained supraorbital ethmoid cells.

5.Persistent polyps.

6.Iatrogenic scarring of the frontal recess and ostium.

Other causes of persistent disease include retained frontal cells, retained supraorbital ethmoid cells, and persistent polyps. These persistent entities may critically obstruct the frontonasal outflow tract and be missed during initial surgeries.

While patients with persistent anatomical obstruction often have excellent outcomes with revision surgical techniques, patients with iatrogenic causes of chronic frontal rhinosinusitis are often the most difficult to cure. Furthermore, iatrogenic scarring and neo-osteogenesis can unfortunately convert a patient with previously mild to moderate symptoms into one with crippling disease. As a result, iatrogenic frontal sinus disease is best avoided by using sound and meticulous technique when performing primary frontal sinus operations.

Commonly, iatrogenic disease is the result of cicatricial scarring from circumferential stripping of the frontal recess mucosa. In addition, mucosal stripping can also lead to neo-osteogenesis, which leads to the deposition of inflamed and hardened bone in the frontal recess, which can be very difficult to remove. Often, a drill is required to remove neo-osteogenesis, and leads to the further risk of greater fibrin deposition, neo-osteogenesis, and eventually restenosis.

Another common cause of iatrogenic disease is frontal sinus mucocele formation. This can be the result of previous frontal sinus procedures such as frontal sinus obliteration with incomplete removal of frontal sinus mucosa, or other less aggressive forms of frontal sinus surgery. Frontal sinus mucoceles can occur several years to decades after previous surgery. They often lead to erosion of the anterior and/or posterior table of the frontal sinus and should be suspected particularly if the patient has had a long asymptomatic interval between symptoms.

■Recurrent frontal sinus disease is most commonly a result of mucosal edema in the frontal recess outflow tract and represents a flare-up of the patient’s underlying mucosal pathology.

Often, recurrent frontal disease responds to topical medical therapy appropriately delivered to the frontal sinus. Also, limited surgery such as a frontal sinus polypectomy or removal of a few remnant cells is often all that is needed to surgically address recurrent frontal sinus disease. The surgeon should pay close attention to the underlying remnant anatomy to see if anatomical variations make the patient prone to recurrences and could be surgically ameliorated. On the other hand, the risk of creating iatrogenic injury and scarring is often higher with revision frontal sinus surgery, and prudence is warranted.

Relevant Anatomy

In particular, the surgeon should look for radiographic evidence of iatrogenic causes of frontal sinusitis including an absent middle turbinate, or a scarred or lateralized middle turbinate or turbinate remnant. Evidence of a residual superior uncinate or remaining anterior ethmoid/frontal cells may reveal evidence for previous inadequate surgery (Fig. 15.2). Given the likelihood of distorted anatomy, the sinus surgeon should have a clear three-dimensional understanding of the anatomy of the patient’s individual frontal recess prior to commencing with surgery. The skull base and the lamina should be carefully evaluated for any potential dehiscence that may be the result of prior surgery, and intraoperatively, suspicious areas should be considered dehiscent unless bone is palpated or confirmed with accurate image guidance. In revision frontal sinus cases, the surgeon should look for the following common causes of pathology:

1.A partially amputated middle turbinate or lateralization of the entire middle turbinate (due to complete resection of the basal lamella) causing obstruction of frontal sinus outflow.

2.Scarring of the superior uncinate to the middle turbinate medial to the frontal sinus outflow tract.

3.Scarring, circumferential stenosis, and/or osteoneogenesis in the frontal ostium area.

4.A remnant ethmoid bulla cap mistakenly considered the frontal recess.

5.Aggernasiorfrontalcellsleftundissected,and/orrecurrence of polyposis in the frontal outflow system [3].

Fig. 15.2  The recessus terminalis is a blind pouch formed by the superior attachment of the uncinate process, as it attaches to lamina papyracea. It can frequently be mistaken for the frontal

Operative Techniques

Surgery for frontal sinus disease should follow an organized progression from least aggressive to most aggressive. There are multiple procedures from which to choose; however, endoscopic procedures should be at the forefront of the thought process when considering frontal sinus surgery. Frontal sinus obliterations should be performed only rarely with the advent of improved frontal sinus instruments and technology.

The endoscopic frontal recess drainage procedure or Draf I procedure is a complete anterior ethmoidectomy with drainage of the frontal recess without manipulation

sinus. The frontal sinus ostium will usually be found posterior and medial to this location

of the frontal sinus outflow tract [7]. It is often used as first-line surgery for management of frontal sinus disease since it carries minimal risk for scarring of the frontal recess; however, it has little role in revision frontal sinus surgery.

Endoscopic Frontal Sinusotomy

Endoscopic frontal sinusotomy involves enlargement of the frontal sinus outflow tract. This extended drainage procedure has been classified into Draf IIA, which corresponds to removing anterior ethmoidal cells that protrude into and/or obstruct the frontal recess (Fig. 15.3). The goal of this procedure is to create an opening of at least 5 mm into the frontal sinus between the middle turbinate medially and the lamina papyracea laterally by removing bony partitions, while sparing frontal recess mucosa. In the presence of a narrow frontal recess, removal of an intersinus septal cell or a Draf IIB procedure may be performed. A Draf IIB involves resection of the frontal sinus floor between the lamina papyracea and the nasal septum (Fig. 15.4). In revision cases, an incomplete previous frontal sinusotomy may be addressed by carefully identifying the true frontonasal outflow tract and removing any obstructing frontal, ethmoid, or agger nasi cells. When the middle turbinates have been resected and the remnant has lateralized and scarred across the frontal sinus outflow tract, the frontal sinus rescue procedure or revision frontal sinusotomy with mucoperiosteal flap

advancement is used to remove any bony and soft-tissue obstruction caused by the destabilized middle-turbinate remnant [1].

External Frontal Sinus Trephination with Endoscopic Frontal Sinus Surgery: the “Above and Below Technique”

Endoscopic approaches to the frontal sinus are usually favored; however, there are some circumstances where the simple trephine along with an endoscopic approach or the “above and below technique” can facilitate the surgery and obviate the need for a more aggressive approach to the frontal sinus. Indications for this procedure are ever expanding since it is minimally invasive and cosmetically

Fig. 15.4  Postoperative view of a Draf IIB procedure

Fig. 15.3  Representative image of a Draf IIA procedure or frontal sinusotomy where ethmoidal cells protrude into frontal recess and removal is necessary via “uncapping the egg”

appealing, yet allows the surgeon to reach areas that are not available via endonasal techniques. Among the indications for the procedure, the most common remain lateral or cephalad frontal sinus lesions, type II or IV frontal cells, which cannot be addressed endoscopically, tumors or inflammatory lesions involving the frontal sinus, frontal sinus trauma, and distorted anatomy of the frontal recess (Fig. 15.5). When performing the trephination, the position of the frontal sinus can be confirmed by utilizing a properly registered and accurate image-guidance system. If image guidance is not available, then the position of the frontal sinus is confirmed on preoperative CT in relation to the supraorbital rim or via a six-foot Caldwell radiograph that can be cut to be used as a template in order to adequately outline the frontal sinus. The endoscopic portion of the surgery should be completed first. After this is done, an incision is made through the medial eyebrow at the level of the supraorbital rim without shaving this region. Once the incision is done, a 4 mm drill bit may be utilized to enter the sinus at the previously confirmed location. The trephine may be enlarged up to 6–8 mm to accommodate instruments as well as the endoscope [6]. Oval-shaped trephinations increase working space while minimizing the chance for cosmetic deformity. Having both the endonasal and external exposure gives the surgeon the advantage of better visualization and improved instrumentation in the area of the frontal sinus, and allows for superior based irrigation of the frontal sinus, which can be very helpful in identifying the frontal recess outflow tract with distorted anatomy as well as in assessing the final opening to the frontal recess after the frontal sinusotomy is completed. The operation is done so that both aspects of the procedure are complimentary (Video 15.1). For example, visualization can be performed endonasally while instrumentation can be done through the trephination, and vice versa. The above

and below approach should be part of any sinus surgeon’s repertoire as it has many applications given its ease of performance, safety profile, and minimal cosmetic disfigurement.

Endoscopic Modified Lothrop or Draf III Procedure

This procedure, also known as the Draf type III procedure, can be utilized as an alternative to osteoplastic flap frontal surgery. The procedure has the surgical objective of creating a large nasofrontal communication by utilizing a totally intranasal approach and avoiding an external incision, while preserving the frontal sinus mucosa [2].

The indications for the endoscopic modified Lothrop procedure include [8]:

1.Failed prior endoscopic sinus surgery techniques.

2.Significant neo-osteogenesis in the frontal recess and frontal ostium.

3.Frontal recess adhesions.

4.Disease processes that have resulted in the loss of the posterior wall or floor of the frontal sinus.

5.Failed previous osteoplastic flap with obliteration and mucocele formation.

6.Tumor removal from the frontal sinus.

The procedure involves identifying the true frontal ostia, 15 which can be difficult, and often is facilitated by the use of computer-aided image guidance, a wire probe, and/or an external minitrephination approach with the use of saline/fluorescein. The superior uncinate and frontal recess

Fig. 15.5  Computed tomography scan: coronal image of a type IV frontal sinus cell

cells are then resected. Drilling is then performed in an anterior direction through the anterior insertion of the middle turbinate until the nasal beak is removed and the nasal bone is reached, and laterally until the plane of the lamina papyracea is reached. A superior 2 × 2 cm septectomy is then performed at the junction of the quadrangular cartilage and perpendicular plate of ethmoid bone. The contralateral frontal sinus floor is then drilled away through the septectomy defect until the opposite lamina papyracea is reached (Fig. 15.6; Video 15.2).

Contraindications to the modified Lothrop procedure include:

1.Hypoplastic frontal sinus and frontal recess.

2.Narrow anteroposterior depth of the frontal sinus.

3.Surgeon inexperience.

4.Lack of proper instrumentation [4].

The modified endoscopic Lothrop is a valuable endonasal approach that should be readily available and always entertained for those patients who are candidates for more aggressive frontal sinus surgery (Fig. 15.7).

Osteoplastic Flap and External Approaches

The osteoplastic flap has been described historically as the definitive procedure for the treatment of recalcitrant frontal sinusitis and frontal sinus disease not amenable to endoscopic approaches [5]. Relative indications to this external approach include chronic frontal sinusitis refractory to endoscopic surgery, mucopyocele, severe trauma with fractures involving the drainage pathways, and after resection of large frontal tumors near the frontal recess. Other external approaches have also been described for the management of frontal sinus disease, but have mostly fallen out of favor.

■Endoscopic procedures not only have the absence of any external scars, but they also help maintain the physiologic ventilation of the sinuses, which is important for radiologic and clinical follow up.

Frontal Sinus Stenting

The indications and benefits of frontal sinus stenting has remained a controversial issue. The purpose of stenting the frontal sinus outflow tract is to minimize stenosis and improve mucosalization (Video 3). Although there are no standardized indications for stenting, there are several situations in which stenting may be considered: (1) the frontal sinus neo-ostium diameter is less than 5 mm,

(2) there is extensive or circumferential exposure of bone

Fig. 15.6  Drilling through the nasal beak to remove the opposite frontal sinus floor and complete the modified Lothrop procedure.

a Drilling through the midline. b Completion of the drilling toward the opposite frontal sinus modified Lothrop procedure

Fig. 15.7  Persistent frontal disease and frontal recess scar formation after multiple sinus surgeries, necessitating more ag-

gressive revision frontal surgery (endoscopic modified Lothrop procedure)

in the frontal sinus outflow tract, (3) there is severe polyposis, or (4) there is a flail, lateralized middle turbinate (Fig. 15.8). While there have been reports of benefits with frontal sinus stenting, there are several known complications:

1.Granulation tissue formation around the stent.

2.Persistent crusting.

3.Migration.

4.Biofilm formation.

Stents maybe a valuable adjunct in frontal sinus surgery, but careful selection and follow up are necessary in order to obtain good results.

Postoperative Care

Meticulous postoperative care is of extreme importance in endoscopic sinus surgery, and particularly in revision frontal sinus surgery. Postoperative care should include, but not be limited to routine nasal saline irrigations, appropriate antibiotic therapy as deemed necessary, as well as topical and systemic agents that control inflammation.

■Endoscopic debridement of the frontal recess is an integral part of good postoperative care.

Meticulous postoperative debridement will allow the 15 removal of any crusts and debris, retained mucus, and blood, which promote inflammation and scarring in the neofrontal ostium. This helps reduce bacterial and/or fungal load and improve mucosal healing. Regular follow up within 1 week after surgery and closely thereafter should be performed in order to ensure that mucosal healing has

Fig. 15.8  Postoperative view of a frontal sinus stent in place

completed. Aggressive medical therapy should also be continued during the perioperative period to control the underlying mucosal disease and avoid restenosis of the frontal sinus outflow tract. Finally, long-term follow up should be individualized for each patient according to the pathophysiology of his or her frontal sinus disease.

Conclusions

For successful outcomes the revision surgeon should first undertake a thorough reevaluation of the patient’s disease, followed by efforts to optimize medical therapy. Next, a thorough investigation into the causes of previous surgical failure should ensue. The choice of procedure used for revision frontal sinus surgery should follow an order from least invasive to most, dictated by the anatomy and CT findings as well as by the underlying pathophysiology. Advancements in optical technology, instrumentation, and image guidance have made revision endoscopic frontal sinus surgery more feasible and safe. Meticulous postoperative care and adherence to individualized medical regimens will lead to greater success in the care of this difficult subset of patients.

References

1.Citardi JM, Javer AR, Kuhn FA (2001) Revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement: the frontal sinus rescue procedure. Otolaryngol Clin N Am 34:123–132

2.Farhat FT, Kountakis SE (2004) Endoscopic modified Lothrop. Oper Tech Otolaryngol Head Neck Surg 15:4–7

3.Friedman M, Bliznikas D, Vidyasagar R, Landsberg R, (2004) Frontal sinus surgery: update of clinical anatomy and surgical techniques. Oper Tech Otolaryngol Head Neck Surg 15:23–31

4.Gross CW, Gross WE, Becker D (1995) Modified transnasal endoscopic Lothrop procedure: frontal drillout. Oper Tech Otolaryngol Head Neck Surg 6:193–200

5.Jacobs JB (2000) Osteoplastic flap with obliteration: is this an ideal procedure for chronic frontal sinusitis? Arch Otolaryngol Head Neck Surg 126:100

6.Patel AM, Vaughan WC (2005) “Above and Below” FESS: simple trephine with endoscopic sinus surgery. In: Kountakis SE, Senior BA, Draf W (eds) The Frontal Sinus. Springer, Berlin, pp 191–199

7.Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD (2001) Modern concepts of frontal sinus surgery. Laryngoscope 111:137–146

8.Wormald PJ (2003) Salvage frontal sinus surgery: the modified Lothrop procedure. Laryngoscope 113:275–283

 Core Messages

■A common and frustrating dilemma associated with sinus surgery is scarring between the middle turbinate and lateral nasal wall.

■The most common adverse event associated with the procedure is failure to alleviate the initial presenting complaints.

■After sinus surgery, mucociliary function of the paranasal sinuses is inhibited for 6–12 weeks.

■Most sinus surgeons feel that aggressive debridement of the postsurgical sinus cavity is critical for success.

■Postoperative debridement may decrease the rate of adhesions and synechiae.

■Postoperative nasal saline irrigations reduce crusting and edema and improve nasal obstruction.

■Intranasal corticosteroids play an integral role in the postoperative management of the surgically treated sinus cavities.

■Because of the multiple side effects of long-term oral steroid use, short oral steroid bursts should be used judiciously, with nasal topical therapy being the preferred treatment.

■In cases of extensive nasal polyps, an ideal solution would involve delivering a large amount of steroid to the diseased sinuses while minimizing systemic absorption.

■Culture-directed antibiotic therapy is necessary for infectious exacerbations of chronic sinus disease, especially after sinus surgery.

Introduction

Functional endoscopic sinus surgery (FESS) is one of the most commonly performed operations by otolaryngologists. The popularity and success of this procedure has been attributed in part to excellent improvement in patient symptoms both in the short term as well as long

term postoperative period [33]. Although much has been written about the rare, devastating complications of FESS – cerebrospinal fluid leak and blindness – the most common adverse event associated with the procedure remains failure to alleviate the initial presenting complaints. Meticulous postoperative care and maximal medical management are widely believed to be crucial to obtaining optimal results. In many respects, the techniques and methods employed after the operation to maintain healthy and open sinus cavities may be as important as the initial surgery itself.

Multiple obstacles can present themselves in the postoperative patient, but a common and frustrating dilemma is scarring between the middle turbinate and lateral nasal wall. This phenomenon often leads to partial or complete obstruction of the ostiomeatal complex with recurrence of symptomatology. After FESS, mucociliary function of the paranasal sinuses is inhibited for 6–12 weeks [16]. Debris composed of fibrin, blood clots, crusts, and viscous secretions tend to accumulate during this time period and the patient is then particularly vulnerable to discomfort, perioperative infection, and postoperative formation of synechiae. Numerous protocols and techniques have been formulated to deal with these challenges and optimize postoperative healing. The decision as to what constitutes the “best” management philosophy is often controversial. This chapter will cover the following major points: postoperative debridement, pros, cons, timing, frequency, nasal saline irrigation and lavage, steroids, oral, topical, and