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52
C. Bachert etal.
Table 5.1
Eosinophils found in sinus specimen
Comorbid asthma (may be before or after CRSwNP diagnosis)
Aspirin or other non-steroidal anti-inammatory sensitivity
Recurrence of nasal polyposis after surgery
Serum eosinophilia (>150 cells/mL of intermediate association, >300 cells/mL strongly
associated)
Clinically relevant allergic rhinitis or other allergic comorbidities (weak association)
Clinical signs for presence of type 2 inammatory disease
smell and/or taste, nasal obstruction, rhinorrhea and/or post-nasal drip, and facial
pain/pressure despite medical therapy. Uncontrolled CRSwNP is dened as persistent or recurring rhinosinusitis symptoms despite long-term(intranasal corticosteroids) INCS, at least one course of systemic corticosteroids in the preceding
2years (or having a medical contraindication to receiving systemic corticosteroids) and/or previous sinonasal surgery (or having a contraindication/unwillingness to undergo surgery).
Indications andSurgical Considerations forReboot Procedure
In patients who have failed previous surgical intervention for type 2 CRSwNP and
report uncontrolled or severe recalcitrant CRSwNP, the reboot procedure can be
considered as an additional surgical option. Additional considerations for the reboot
procedure are included in Table5.2.
When former surgery is reported, an estimation of the kind and extent of this
operation should be deduced from available reports, nasal endoscopy, and eventually CT scanning. Which sinuses have been approached (were the frontal and sphenoid sinuses included?), and has a “ventilation and drainage” approach or a
“mucosal” approach been performed? Have the sinuses been opened and clearly
thickened mucosa been removed (partially) or did the surgeon aim to (almost) completely remove the sinus mucosa, as described under the terms “nasalization” [13]
or “reboot” [14]? Are those openings still functional, and can the sinuses be
inspected with the endoscope? What is the condition of the sinus mucosa in the various sinuses? Healthy, thickened, are there secretions and crusts? The ultimate aim
of surgical intervention is to provide an open ostium and a non-inamed relatively
thin sinus mucosa without colored secretions in all sinuses (Fig.5.2).
If these sinus conditions are not achieved and the patient still has symptoms
derived from remaining pan-sinus disease, a reboot surgery approach in severe
CRSwNP should be considered. The authors also advocate consideration of the
reboot procedure as a primary procedure in patients who suffer from severe uncontrolled bilateral type 2 CRSwNP disease.
5 The Reboot Procedure forSevere Chronic Rhinosinusitis withNasal Polyps
53
Table 5.2
indications for reboot
procedure in patients
with CRSwNP
Fig. 5.2 View into the
ethmoid after Reboot
surgery; maxillary and
sphenoid sinuses
accessible, no polyps
visible
Potential
Involvement of equal to or more than two sinuses on
both sides
Comorbid asthma
Comorbid aspirin sensitivity (NSAID)
Increased blood eosinophils
Failure of previous surgical intervention with return of
nasal polyposis
Surgical Principles andConsiderations
For the reboot procedure, standard techniques for endoscopic sinus surgery should
be applied, with an emphasis on broad openings of each of the sinuses. Once this is
obtained, the inamed mucosa of the sinuses should be removed. Typically, the
inamed mucosa of the sinuses is easily removable with the typical instruments for
sinus surgery including grasping instruments like the antrum grasping forceps
“Heuwieser” or Blakesley’s forceps. The principles of reboot surgery are listed in
Table5.3.
Removal of mucosa may lead to some bleeding from the underlying bone upon
immediate removal. This tends to improve quickly but may also be aided by the
application of topical vasoconstrictors and/or foam-based hemostatic agents. Nasal
packing may be necessary for additional hemostasis.
After completion of the surgery, the nasal re-mucosalization will extend from the
edges of the stripped mucosa in the nose into the sinuses within just a few days, and
often can be observed to cover most of the maxillary and ethmoidal sinuses after
54
C. Bachert etal.
Table 5.3
(a) Broadly opening of the ethmoid, maxillary, frontal and sphenoid sinuses
(b) Completely removing the sinus mucosa of the maxillary and ethmoid sinuses
(c) Completely removing the sinus mucosa of the sphenoid and frontal sinuses. In cases where
these sinuses demonstrate normal mucosa, the mucosa can be spared
(d) Preservation of the nasal mucosa of the inferior turbinate, middle turbinate (if without
polyp growth), superior turbinate, the lateral nasal mucosa of the pre-maxillary and preethmoidal regions, the olfactory cleft mucosa
Principles of reboot surgery
just 1 week. After 2 weeks, the total surgical eld is often fully re-mucosalized with
a thin, but functional mucosa. It is important in this period of wound healing to
avoid infections. The authors will often provide doxycycline 200mg initially, then
100mg/day, given prophylactically for up to 4weeks to minimize the risk of infection. These patients should be closely observed to ensure sinus stenosis does not
occur. The authors advocate for early and frequent use of topical sinus irrigations
twice daily and debridement of the sinuses at 1 and 2weeks post-operatively. Any
early stenosis should be promptly dilated and scar bands cut. We see the patients
post-operatively for cleaning and control of pain up to once a week for the rst
4 week. The post-operative wound healing period is mostly completed within
8–12weeks.
Only occasionally, the frontal sinus ostia have to be enlarged with the help of
bougies or balloons, or small single polyps from any sinus have to be removed
within that time. At the end of this period, all sinuses should be accessible, free of
infection and edema formation. Temporary hyposmia is anticipated but does
improve. Within 6–12months, >80% of the formerly anosmic subjects regain smell.
To avoid CRSwNP recurrence and to support the smell potential, topical steroid
rinses are continued after surgery twice daily for up to 3 years and once daily thereafter, provided the mucosa remains free of polyp burden.
Another approach is the combination of surgery with biologic drugs such as
Omalizumab, Mepolizumab, Dupilumab, or Benralizumab [8–11]. The indication
for biologics is discussed in Chap. 25 of this book; however, when Reboot surgery
is planned and the sinus mucosa is completely removed, a combination with biologics may not be needed.
Reported Outcomes
The authors’ own data show that markers of Type-2 inammation in secretions
decrease post-operatively, and smell improves within one to 3 months and is maintained at a functional level over a follow-up of 6months or longer (up to 5years
documented). Recurrence of nasal polyps rarely occurs, and if so, mostly localized
areas of minor disease may occur. In these cases, small polyps can be removed
inlocal anesthesia. The need for revision surgery for CRSwNP is low (below 10%
over 5years).
5 The Reboot Procedure forSevere Chronic Rhinosinusitis withNasal Polyps
55
Tips and Pearls
• Create a relatively large enough ostium such that you can visualize the complete
sinus cavities and visibly verify complete removal of the sinus mucosa.
• For removal of the maxillary oor sinus mucosa, the “Heuwieser” bended grasp-
ing forceps or frontal instruments may be helpful.
• The frontal sinus ostium enlargement anteriorly and medially can be achieved
with the Bachert frontal sinus punch, which can be used to remove the bony
frontal sinus oor.
• Blakesley’s with different angles (up to 90°) are helpful for the maxillary ostium
and the anterior ethmoid approach to the frontal sinus.
• The inferior turbinate as well as the middle turbinate should be maintained as
much as possible, as they only seldomly develop nasal polyps and serve the
humidication of the ambient air post-operatively.
• Strictly avoid stripping of mucosa in the olfactory cleft or removal of the superior
turbinate to minimize the risk of postoperative hyposmia.
References
1. Bachert C, Wagenmann M, Hauser U, Rudack C.IL-5 is upregulated in human nasal polyp
tissue. J Allergy Clin Immunol. 1997;99:837–42.
2. Tomassen P, Vandeplas G, van Zele T, Cardell LO, Arebro J, Olze H, Förster-Ruhrmann U,
Kowalski ML, Olszewska-Ziąber A, Holtappels G, De Ruyck N, Wang XD, Van Drunen C,
Mullol J, Hellings P, Hox V, Toskala E, Scadding G, Lund V, Zhang L, Fokkens W, Bachert
C.Inammatory endotypes of chronic rhinosinusitis based on cluster analysis of biomarkers.
J Allergy Clin Immunol. 2016;137(5):1449–56.
3. De Loof M, De Leenheer EMR, Holtappels G, Bachert C.Cytokine prole of nasal and middle
ear polyps in a patient with Woakes’ syndrome and eosinophilic otitis media. BMJ Case Rep.
2016;2016:bcr2016215054.
4. Alsharif S, Jonstam K, van Zele T, Gevaert P, Holtappels G, Bachert C. Endoscopic sinus
surgery for Type-2 CRSwNP: an Endotype-based retrospective study. Laryngoscope.
2019;129(6):1286–92.
5. Bachert C, Han JK, Wagenmann M, Hosemann W, Lee SE, Backer V, Mullol J, Gevaert P,
Klimek L, Prokopakis E, Knill A, Cavaliere C, Hopkins C, Hellings P. EUFOREA expert
board meeting on uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) and
biologics: denitions and management. J Allergy Clin Immunol. 2021;147(1):29–36.
6. Bachert C, Zhang N, Holtappels G, De Lobel L, van Cauwenberge P, Shixi L, Lin P, Bousquet
J, van Steen K.Presence of IL-5 protein and IgE-antibodies to staphylococcal enterotoxins in
nasal polyps is associated with co-morbid asthma. JACI. 2010;126:962–8.
7. Bachert C, Zhang N, Holtappels G, Tomassen P, Liu S, Lin P, Bousquet J.Nasal polyp endotypes: IL-5 and asthma co-morbidity. J Allergy Clin Immunol. 2011.
8. Gevaert P, Omachi T, Corren J, Mullol J, Han J, Lee SE, Kaufman D, Ligueros-Saylan M,
Howard M, Zhu R, Owen R, Wong K, Islam L, Bachert C.Efcacy and safety of omalizumab
in nasal polyposis: two randomized 1 phase III trials. JACI. 2020;146:595–605.
9. Han JK, Bachert C, Fokkens W, Desrosiers M, Wagenmann M, Lee SE, Smith SG, Martin
N, Mayer B, Yancey SW, Sousa AR, Chan R, Hopkins C, SYNAPSE study investigators.
Mepolizumab for chronic rhinosinusitis with nasal polyps (SYNAPSE): a randomised, doubleblind, placebo-controlled, phase 3 trial. Lancet. Respir Med. 2021;9(10):1141–53.
10. Bachert C, Han JK, Desrosiers M, Hellings PW, Amin N, Lee SF, Mullol J, Greos LS, Bosso
JV, Laidlaw TM, Cervin A, Maspero JF, Hopkins C, Olze H, Canonica GW, Paggiaro P, Cho
https://doi.org/10.1136/bcr- 2016- 215054.
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SH, Fokkens W, Fujieda S, Zhang M, Lu Y, Fan C, Draikiwicz S, Kamat SA, Khan A, Pirozzi
GL, Patel N, Graham N, Ruddy M, Staudinger H, Weinreich CD, Stahl N, Yancopoulos GD,
Mannent LP.Dupilumab efcacy and safety in severe chronic rhinosinusitis with nasal polyps
in the multicentre, randomised, double-blind, placebo-controlled, parallel group phase 3 trials
LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52. Lancet. 2019;394(10209):1638–50.
11. Bachert C, Han JK, Desrosiers MY, Gevaert P, Hefer E, Hopkins C, Tversky JR, Barker P,
Cohen D, Emson C, Martin UJ, Shih VH, Necander S, Kreindler JL, Jison M, Werkström
V.Efcacy and safety of Benralizumab in chronic rhinosinusitis with nasal polyps: a randomized, placebo-controlled trial. J Allergy Clin Immunol. 2021;S0091–6749(21):01459–7.
12. Calus L, Van Bruaene N, Bosteels C, Dejonckheere S, Van Zele T, Holtappels G, Bachert C,
Gevaert P.Twelve-year follow-up study after endoscopic sinus surgery in patients with chronic
rhinosinusitis with nasal polyposis. Clin Transl Allergy. 2019;9:30.
13. Jankowski R, Rumeau C, Nguyen DT, Gallet P.Updating nasalisation: from concept to technique and results. Eur Ann Otorhinolaryngol Head Neck Dis. 2018;135(5):327–34.
14. Costa Gomes S, Cavaliere C, Masieri S, Van Zele T, Gevaert P, Holtappels G, Zhang N,
Ramasamy P, Voegels RL, Bachert C.Reboot surgery for CRSwNP: recurrence and smell
kinetics. Eur Arch Otorrinolaringol. 2022;279:5691.
C. Bachert etal.
Sphenoid Drill-out forRecalcitrant
Chronic Sphenoid Rhinosinusitis
WilliamDerekLeight andDonaldArthurLeopold
Key Points
• The management of chronic sphenoid rhinosinusitis (CSR) recalcitrant to medi-
cal therapy is time consuming and difcult.
• Sphenoid drill-out is a safe and effective technique that allows large volume
irrigation to the sphenoid analogous to a Draf III with a procedure time and
degree of invasiveness similar to a Draf IIb.
• It is a versatile technique that can be combined with other extended approaches
to the frontal and maxillary sinuses, as well as previously described extended
sphenoid surgery techniques, such as mini-nasoseptal ap or nasoseptal rescue ap.
• The technique is a natural transition for most sinus surgeons who perform endo-
scopic approaches to the pituitary.
• The sphenoid drill-out should be reserved for recalcitrant disease and revision
surgery, or in cases of difcult primary disease with high likelihood of recurrence due to anatomic factors.
6
Donald Arthur Leopold passed away during the composition of this chapter.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_6.
W. D. Leight (*) · D. A. Leopold
Ear, Nose and Throat Institute, Boys Town National Research Hospital, Boys Town, NE, USA
e-mail: William.Leight@boystown.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee et al. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_6
57
58
W. D. Leight and D. A. Leopold
Background
Chronic sphenoid rhinosinusitis (CSR) recalcitrant to medical and surgical therapy
may result from advanced chronic infectious or inammatory disease, anatomic factors, or inadequate initial surgical/postoperative management of primary chronic
sphenoid rhinosinusitis. It is often multifactorial [1]. Persistent inammatory disease in the sphenoid more commonly results from systemic factors leading to sphenoid sinusitis in the setting of chronic pansinusitis (Fig.6.1) and occasionally from
local factors resulting in isolated chronic sphenoid rhinosinusitis (Fig.6.2).
In cases of revision sinus surgery, the sphenoid will be involved approximately
30–50% of the time [2, 3]. The goal of surgical management in recalcitrant chronic
sphenoid rhinosinusitis is to improve sphenoid function and mucociliary clearance
by removing irreversibly inamed mucosa, neo-osteogenic bone, and scar. In most
cases of refractory chronic sphenoid inammation, long-term topical therapy will
be required, and optimizing the sphenoid for maximal high volume, low pressure
saline irrigation is therefore also key in long term management [4]. While a traditional type I, II, or III sphenoidotomy [5] is highly effective in the management of
most cases of primary surgery for chronic sphenoid rhinosinusitis, extended procedures are sometimes needed for advanced disease [6].
The sphenoid drill-out is a modication of the traditional bilateral sphenoidotomy that allows for the creation of a single common sphenoid cavity by removal of
the rostrum, posterior nasal septum and sphenoid intersinus septum in order to maximize irrigation volume and topical drug delivery (Fig.6.3). In the surgical hierarchy of chronic sphenoid rhinosinusitis, it lies between traditional sphenoidotomy
and sphenoid marsupialization, which requires extensive drilling of the clivus to
fully eliminate the need for mucociliary transport [7]. Although it is conceptually
similar to a Draf III in the frontal sinus in that a single common cavity is created, in
the degree of invasiveness and time required, it is more similar to a Draf IIb. This
allows it to be readily performed in the same setting as extended approaches to the
maxillary and frontal sinuses [8, 9].
Fig. 6.1 Coronal and axial computed tomography (CT) images of a patient with aspirin exacerbated respiratory disease after 3 previous surgeries
6 Sphenoid Drill-out forRecalcitrant Chronic Sphenoid Rhinosinusitis
Fig. 6.2 Coronal and axial CT images of a patient with an isolated sphenoid sinus mycetoma
without prior surgical intervention. Notice intense inammatory changes and neo-osteogenesis
and absence of a portion of sphenoid intersinus septum despite no prior surgery
Fig. 6.3 Long-term
postoperative result from a
patient who has undergone
sphenoid drill-out. Notice
absence of rostrum and
intersinus septum as right
(R) and left (L) sphenoid
cavity can be appreciated
together in the same eld
as the planum sphenoidale
(P) using a 0-degree
endoscope
59
Surgical Indications
Sphenoid drill-out should be considered primarily for surgical salvage. Patients
requiring sphenoid drill-out have typically had one or more prior sphenoidotomies.
Only rarely should it be performed in the primary surgical setting [8, 9]. Patients
typically have impaired mucociliary clearance and advanced mucosal disease
(Table 6.1). Advanced chronic rhinosinusitis with and without nasal polyps
60
W. D. Leight and D. A. Leopold
Table 6.1
1. Recalcitrant sphenoid sinusitis in the presence of:
(a) Isolated sphenoid sinusitis with neo-osteogenesis and/or aggressive synechiae formation
(b) Recurrent sphenoid mycetoma
(c) Sphenoid mycetoma with severe neo-osteogenesis
(d) Chronic rhinosinusitis with and without nasal polyposis
(e) Eosinophilic mucin chronic rhinosinusitis with nasal polyposis
(f) Aspirin exacerbated respiratory disease (AERD)
(g) Eosinophilic granulomatosis with polyangiitis (EGPA)
(h) Granulomatosis with polyangiitis (GPA)
(i) Recurrent allergic fungal rhinosinusitis
(j) Cystic brosis
(k) Primary ciliary dyskinesia
2. Neoplasia
3. Recurrent sphenoid mucocele with neo-osteogenesis or bone erosion
Indications for sphenoid drill-out
Fig. 6.4 On the left, axial CT image from a patient with AFRS after two previous surgeries. Note
extensive inammatory disease, bony remodeling, high density inltrates, and multiple areas of
skull base dehiscence. On the right, 0-degree endoscopic view of same patient 5years after a sphenoid drill-out procedure
(CRSwNP, CRSsNP), eosinophilic mucin chronic rhinosinusitis with nasal polyps
(eCRSwNP), allergic fungal rhinosinusitis (AFRS) (Fig.6.4), aspirin exacerbated
respiratory disease (AERD) (Fig.6.1), cystic brosis, sphenoid mycetoma (Fig.6.2),
sphenoid mucocele (Fig.6.5), and eosinophilic granulomatous polyangiitis (EGPA)
with CRS are some of the conditions that are more likely to require a sphenoid
drill-out.
6 Sphenoid Drill-out forRecalcitrant Chronic Sphenoid Rhinosinusitis
Fig. 6.5 Coronal CT image revealing a mucocele surrounded by severe osteoneogenesic bone in
the right sphenoid
61
Surgical Technique
The technique has similar elements to an endoscopic approach to lesions of the
sella. Stereotactic computed tomography (CT) guidance is recommended due to the
enhanced difculty usually encountered in terms of anatomic landmarks, inammatory change, scar, neo-osteogenesis, increased blood loss, and presence of vital neurovascular structures in the region. 1% lidocaine with 1:100,000 epinephrine is
injected into the lateral nasal wall just anterior to the sphenopalatine foramen, as
well as into the posterior nasal septum. In the absence of other mitigating factors,
the less diseased sphenoid is addressed rst. This allows for better access and visualization when addressing the more severely diseased sinus later.
Any revision surgery that needs to be accomplished in the maxillary and ethmoid
sinuses is performed rst. If a Draf III is planned, the entire sphenoid drill-out is
performed prior to addressing the frontal sinuses. Most commonly, a trans-ethmoid
approach to the sphenoid is used, as most of these cases are done in the setting of
refractory pansinusitis; however a trans-nasal approach is possible.
If present, the superior turbinate or its remnant is partially resected. The natural
or surgical ostium of the sphenoid is identied if present. If small, a stapes curette
or J-curette are typically used to gently enlarge the ostium initially. A wide sphenoidotomy is then performed with a variety of Kerrison rongeurs using a standard
push-pull technique. These are ideal instruments for revision sphenoid surgery, as
they allow for forceful removal of thickened bone and mucosa in a controlled fashion that minimizes risk to nearby structures. Having a wide array of rongeurs of
different angles and sizes can greatly aid this portion of the dissection. As the initial
sphenoidotomy is being performed, care is taken to identify the important landmarks of the sphenoid including the sella, carotid artery, optico-carotid recess, optic
nerve, and lateral recess (if present) with V2 and vidian nerves.