Revision Endoscopic Sinus Surgery Noam A. Cohen, MD, PhD, David W. Kennedy, MD * Division of Rhinology, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania School of Medicine, 5th floor Ravdin Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104 Functional endoscopic sinus surgery (FESS) has a long-term high rate of success (approximately 90%) for symptomatic improvement in patients with medically refractory chronic rhinosinusitis [1]. As the popularity of the tech- nique continues to grow, however, so does the population of patients with postsurgical persistent sinus disease. This subset of patients often represents a challenge to the otorhinolaryngologist. Essential to management of these patients is identification of the source of persistent disease. These etiologies are best classified broadly as environmental, host, or iatrogenic. Although the focus of this article is iatrogenic issues, the topic of revision FESS cannot be discussed fully without mentioning environmental or host factors. The central dogma of FESS is restoration of the natural sinus physiology (ie, mucociliary clearance). Environmental factors that pose a risk to the mucociliary apparatus, through toxicity or induction of mucosal inflamma- tion, must be minimized if not outright eliminated. Common factors include air pollutants, allergens, tobacco smoke, and mold. Likewise, host factors that hinder mucociliary clearance or result in excessive inflammation must be reversed or improved. Questions addressing systemic disease, such as asthma, aspirin intolerance, immunodeficiencies, cystic fibrosis, granuloma- tous disease, primary ciliary dyskinesia, and neoplasia, should be asked. Na- sal polyposis is a common cause for revision surgery and is most likely a manifestation of a combination of environmental exposure with excessive host response. Even with a well-executed surgical dissection, in the absence of addressing environmental and host mucociliary risk factors, failure is imminent in primary and revision surgery. Iatrogenic disease may result from poor surgical technique, inadequate postoperative cavity de´ bridement, or inadequate postoperative medical care. Mucosal preservation is paramount for success. Surgical technique * Corresponding author. E-mail address: david.kennedy@uphs.upenn.edu (D.W. Kennedy). 0030-6665/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2006.01.003 oto.theclinics.com Otolaryngol Clin N Am 39 (2006) 417–435