BackTable / ENT / Podcast / Episode #30
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.
BackTable, LLC (Producer). (2021, August 31). Ep. 30 – Revision Endoscopic Sinus Surgery [Audio podcast]. Retrieved from https://www.backtable.com
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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 practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
In this episode, Dr. Ashleigh Halderman joins Dr. Gopi Shah and Dr. Ashley Agan to discuss preoperative, procedural, and postoperative considerations for revision sinus surgery.
Dr. Halderman begins by describing her patient workup, which includes learning about the patient’s history with sinus problems and surgeries. It is critical to learn about the patient’s current maintenance regimen and whether it includes sinus rinses, steroids, and/or antibiotics. Dr. Halderman aims to teach patients how to maximize medical management techniques before performing a revision surgery. She discusses the steroids and antibiotics that she usually prescribes and her patient education technique for nasal rinses.
In addition, she conducts physical and endoscopic exams and obtains a preoperative CAT scan. She emphasizes that the CAT scan is important for determining the extent of the prior surgery and guiding future plans. Sometimes, the scan reveals that a patient’s symptoms are not sinus-driven (i.e. recurrent viral infections), leading her to consider options besides surgery.
Finally, the doctors discuss operative technique. Revision surgeries may be challenging due to abnormal anatomy and scarring, so Dr. Halderman advises surgeons to utilize image guidance and look for anatomical landmarks.
The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery:
[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.
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