Is bilateral image-guided endoscopic sinus surgery indicated for a patient with recurrent and chronic sinusitis, and acute maxillary sinusitis?

Bilateral Image-Guided Endoscopic Sinus Surgery is Indicated for This Patient

This patient with chronic rhinosinusitis, recurrent acute exacerbations, complete maxillary sinus opacification with a large cystic structure, and prior sinus surgery meets clear criteria for bilateral image-guided endoscopic sinus surgery including ethmoidectomy, maxillary antrostomy, sphenoidotomy, and frontal sinus exploration. 1

Rationale for Surgical Intervention

Medical Management Has Been Exhausted

• Patients should be referred for surgery after medical treatment options have been exhausted and CT imaging demonstrates disease amenable to surgical correction 1
• The 2025 American Academy of Otolaryngology guideline confirms that sinus surgery is indicated when chronic rhinosinusitis is refractory to appropriate medical management 1
• This patient has recurrent sinusitis with severe symptoms (10/10 pain for 2 weeks) despite prior surgical intervention, indicating failure of conservative approaches 1

Objective Confirmation of Disease

• CT imaging demonstrates complete opacification of the left maxillary sinus with a large cystic structure—this represents objective evidence of significant sinonasal inflammation requiring surgical intervention 1
• The presence of a large cystic structure within the maxillary sinus (likely a mucocele or retention cyst) is a specific indication for endoscopic sinus surgery 2
• Mucoceles treated with endoscopic sinus surgery show resolution of symptoms and patent antrostomy on long-term follow-up in all cases, with no revision surgery required 2

Image-Guided Surgery is Specifically Indicated

Previous Surgery Creates Altered Anatomy

• Image-guided CT is essential when previous surgery has removed landmarks 1
• This patient has prior history of sinoplasty and rhinoplasty, making image-guided navigation critical for safe surgical approach 1
• Image-guidance technology is beneficial in revision surgery cases and provides intraoperative localization of complex frontal sinus outflow anatomy 3

Complex Disease Requiring Full Exposure

• When the sinus involves cystic lesions or requires removal of diseased tissue, the surgeon should perform sinus surgery that includes full exposure of the sinus cavity and removal of diseased tissue, not just balloon or manual ostial dilation 1
• The large cystic structure requires complete visualization and removal, which necessitates comprehensive surgical approach 1

Extent of Surgery is Appropriate

Bilateral Approach

• Although the CT shows unilateral left maxillary disease, the patient has chronic rhinosinusitis affecting multiple sinus systems 1
• The osteomeatal complex obstruction can affect frontal, anterior ethmoid, and maxillary sinuses due to their dependent drainage through this region 4

Comprehensive Sinus Clearance

• Ethmoidectomy with middle meatal antrostomy should be performed for inflammatory maxillary sinus disease 2
• Frontal sinus exploration is justified given the chronic nature and recurrent pattern of disease 5, 6
• Meticulously performed endoscopic frontal sinusotomy with computer guidance is effective in treating chronic frontal sinusitis secondary to outflow tract obstruction 5
• The Messerklinger technique aims for underlying causes in ethmoid compartments, widening stenotic clefts and freeing prechambers to frontal and maxillary sinuses 6

Septoplasty and Turbinate Reduction

• These adjunctive procedures improve surgical access and long-term sinus drainage 2
• Middle turbinectomy is commonly performed alongside ethmoidectomy and antrostomy to maintain patent drainage pathways 2

Critical Preoperative Requirements

CT Imaging Protocol

• A fine-cut CT protocol must be obtained for surgical planning if not already available 1
• CT imaging should be imported into computer navigation systems for image-based guidance surgery 1
• The registration process must create accuracy within 2 mm between operative field and imaging data 1

Patient Education Requirements

• The surgeon must educate the patient regarding anticipated postoperative care: pain control, debridement, medical management, activity restrictions, return to work, duration and frequency of follow-up visits, and potential for recurrent disease or revision surgery 1
• Patients must understand the expectation for long-term disease management following surgery 1

Postoperative Management

Mandatory Follow-Up

• Routine follow-up must occur between 3 and 12 months after surgery to assess outcomes through history (symptom relief, quality of life, complications, adherence to therapy, need for rescue medications) and nasal endoscopy 1
• Endoscopic frontal sinusotomy shows 19% recurrence rate with only 8% requiring revision surgery when meticulously performed 5
• Patients not requiring revision can be treated satisfactorily with topical medications in outpatient clinic 5

Common Pitfalls to Avoid

• Do not plan extent of surgery solely based on arbitrary criteria regarding minimal mucosal thickening or sinus opacification on CT—clinical correlation with symptoms and endoscopic findings is essential 1
• Do not perform simple balloon dilation or ostial dilation alone when cystic lesions, polyps, or significant tissue disease is present—full exposure and tissue removal is required 1
• Ensure adequate training and experience with image-guided systems, as the technique carries risks of orbital or skull base injury if improperly performed 1