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The authors have developed an acronym to aid evaluation of preoperative sinus CT imaging in revision endoscopic sinus surgery (RESS). To determine which pertinent aspects of anatomy to include, a systemic review of studies that investigated anatomic contributions to persistent chronic rhinosinusitis (CRS) requiring RESS was conducted. Excluded studies were those of paediatric populations, non-endoscopic techniques, non-CRS disease, non-English studies, and those that did not assess anatomical contributions. Out of 599 articles that met screening criteria, 27 were included in the final review. Most of the included studies were case series (25/27), altogether comprising a total of 1973 revision surgeries. Using the information from the systematic review, they formed the acronym REVISIONS covering anatomical sites that led to recurrent or persistent CRS in greater than nine individual studies. REVISIONS stands for: Residual uncinate, Ethmoid cells (agger, Haller, supraorbital), Vessels (anterior and posterior ethmoid), Infundibulum, Septal deviation, I (eye) compartment, Onodi cell, Natural os, and Skull base slope and integrity. Importance of adequate uncinate removal was heavily noted in the studies included, as failure to do so prevents identification of the natural maxillary sinus ostium and medication delivery to the osteomeatal complex (OMC). Residual ethmoid cells were the most commonly identified anatomical finding (up to 92% in patients undergoing RESS). Failure to address them can lead to impairment of frontal sinus drainage. The anterior and posterior ethmoidal arteries can be identified radiographically and are important to consider to avoid haemorrhagic complications. The infundibulum component relates to the middle turbinate (lateralisation, pneumatisation or inflamed mucosa) and posterior uncinate process. Septal deviation could contribute to OMC obstruction, synechiae formation, diminished access for surgery and medication. Orbital bony dehiscence predisposes to orbital injury and adequate lamina papyracea exposure intraoperatively minimises risk of inadvertent orbital injury. Onodi cells are important to recognise because of their relationship to the internal carotid artery and sphenoid sinus. Natural ostia are usually widened as part of surgery. Failure to incorporate the natural ostium in an antrostomy can be identified radiographically and leads to mucociliary recirculation. Assessment of the skull base is important to identify its degree of sloping, integrity and anatomical variants.

Creation of a Novel Preoperative Imaging Review Acronym to Aid in Revision Endoscopic Sinus Surgery.
Karadaghy OA, Peterson AM, Fox M, et al.
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Richard (Wei Chern) Gan

Bradford Royal Infirmary, UK.

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