I'm pretty much in the same boat.  I got in to see a researcher and
he told me that although I am pretty open from surgery I still have
an infection.  He said one leading theory right now is that bacteria
grows on the surface of the sinus lining and develops a biofilm to
protect itself from antibiotics.  He mentioned a family of drugs
(which I can't remember right now) that may hold some promise.
There's other theories too but not many ent's will treat you based
on one.  Bottom line...  IMO, your screwed till there's a true
breakthrough.  I'll bet we're 10 years or more away from a cure.

long shot....

i got a different infection after having FESS... a nasty bug i picked up at
the hospital. anyways, they did a C&S and identified the bug (pseudomonas).
four months and five antibiotics later i was finally rid of it.

anyways, i think the nasal rinse/spray of the antibiotic and the oral
antibiotic combination was the most effective treatment.

i don't know what "bug" you all are suffering from, but the double whammie
(oral and topical) antibiotic worked for me.

best wishes

Has your ENT considered that you may have a recirculation disorder
caused by a slight problem with your surgeries?  Here is an article you
might show him:

Iatrogenic maxillary sinus recirculation and beyond. (Original Article).

Ear, Nose & Throat Journal, Jan, 2003, by Michael Gutman, Steve Houser

Abstract

Recirculation of nasal mucus occurs when secretions that have been
transported out of the natural maxillary ostium return to the sinus via
a surgically created or accessory ostium. Recirculation increases the
risk of persistent sinus infection. In this article, we describe a case
of mucus recirculation in a patient who had not responded to two
previous sinus surgeries for recurrent rhinosinusitis. We also postulate
the possibility of ethmoid recirculation.

Introduction

Functional endoscopic sinus surgery has been a most successful
procedure, and clinical failure rates of less than 10% have been
reported in the literature. (1) According to the Messerklinger approach,
the key to eliminating persistent sinus infection is to re-establish
physiologic mucociliary clearance patterns. (2) Patients in whom sinus
surgery has failed have often exhibited evidence that their mucociliary
clearance pathways were functionally or anatomically obstructed. One
functional mechanism that has been well described is the recirculation
phenomenon. (3,4)

Recirculation occurs when secretions that have been transported out of
the natural maxillary ostium return to the sinus via a surgically
created or accessory ostium; the process then becomes cyclical. (5)
Matthews and Burke described the adverse effect of recirculation: "The
putative mechanism of sinus disease related to this recirculation
involves the repeated presentation of allergens, bacteria, and
inflammatory mediators contained in the mucus. If the mucus is not
cleared, its viscidity increases, and its concentration of inflammatory
agents increases its potential for inducing sinus mucosal inflammation
and disease." (6)

In this article, we describe our endoscopic identification of an
incontrovertible case of mucus recirculation in a patient who had not
responded to two earlier sinus surgeries for recurrent rhinosinusitis.
We also emphasize the principles of the diagnosis and treatment of
recirculation, and we postulate the possibility of ethmoid recirculation.

Case report

In 2000, we evaluated a 48-year-old man who had recurrent rhinosinusitis
despite having undergone sinus surgery in 1996 and 1997. He had
experienced a brief period of relief following the second operation, but
thereafter several acute infections of worsening severity ensued. During
our initial evaluation, the patient complained of severe nasal
congestion and thick postnasal drainage despite more than 4 weeks of
culture-specific antibiotic therapy. Adjunctive nasal irrigation had
also been unsuccessful in alleviating his symptoms.

Fiberoptic examination of the nasal cavities revealed that the
iatrogenic ostia were patent bilaterally. A drop of turbid mucus was
detected resting above the left iatrogenic ostium. Computed tomography
(CT) detected a bilateral soft-tissue obstruction of the natural ostia,
which were discontinuous with the surgically created ostia (figure 1).

Based on these findings, the patient was taken for revision endoscopic
sinus surgery. Intraoperatively, we noted that a tenacious ring of clear
mucus was circulating through the natural and iatrogenic maxillary ostia
(figure 2). To connect the two ostia, we inserted the ball-tipped end of
the Houser Freer-seeker (Instrumentarium Surgical Corp.; Terrebonne,
Que.) into the natural ostium and pulled it downward into the large
iatrogenic ostium. We then sharply debrided the tissue remnants with the
Hummer microdebrider (Stryker Leibinger; Kalamazoo, Mich.). We also
performed bilateral revision anterior and posterior ethmoidectomies, a
right frontal sinusotomy, and a reduction of the inferior turbinates.

Follow-up endoscopy 3 months following surgery revealed that the new
ostium was widely patent and well healed (figure 3). At 14 months, the
patient reported a significant improvement in his condition; compared
with his preoperative state, he was experiencing less congestion, mucus
formation, and fatigue. Since then, he has required one course of
antibiotic treatment. He continues to use a nasal irrigator periodically
as needed (less frequently than before) and he continues to use a
steroid nasal spray regularly.

Discussion

Under normal circumstances, clearance from the maxillary sinus proceeds
from the natural ostium, which is usually located in the posterior third
of the ethmoid infundibulum. (7) The secretions then traverse from the
hiatus semilunaris to the medial wall of the inferior turbinate, and
then they move posteriorly to the nasopharynx. It has been well
established that mucus is cleared from the maxillary sinus via the
natural ostium even in the presence of large nasoantral or middle meatal
windows that are separate from the natural ostia. (2) In our patient,
the CT finding of discontinuity between the natural and iatrogenic ostia
led us to suspect that recirculation had been occurring. Our suspicion
was confirmed endoscopically. During surgery, we re-established a
physiologic mucociliary pathway by connecting the two ostia in the
manner described by Coleman and Duncavage. (8)

Theoretically, recirculation can occur in any sinus that has an
accessory or iatrogenic ostium through which mucus can return to the
sinus. The recirculation phenomenon has been observed in the sphenoid
sinus.9 It has also been documented in a maxillary sinus following the
creation of nasoantral windows. Recirculation has even been documented
by graphite tracing in the ethmoid cavity following posterior
ethmoidectomy. (10) We suggest that recirculation can occur following an
anterior ethmoidectomy as well; such a process has not been previously
reported in the literature.

During an anterior ethmoidectomy, the typical first step is to perforate
the anteroinferior wall of the ethmoid bulla. A microdebrider or forceps
is then used to more fully open the bulla. If only an anterior
ethmoidectomy is indicated, then the surgeon might inadvertently leave
the posterior wall of the bulla intact. The posterior wall of the bulla
tightly overlies the retrobullar space and basal lamella. The natural
drainage point for the ethmoid bulla is frequently located at the most
lateral part of the posterior bullar wall. This point would remain
discontinuous with the iatrogenic defect if a bridge of posterior bullar
wall that is medial to the natural ostium remains intact. According to
the findings of Waguespack's study of mucociliary clearance following
sinus surgery, mucus situated on the lamina papyracea, previously the
lateral wall of the bulla, will flow posteriorly onto the basal lamella.
(10) We suspect that this mucus could easily loop back over the
surgically created bridge of tissue and est ablish a circular flow pattern.

In order to prevent ethmoid recirculation, we prefer to identify the
ostium of the bulla and resect the bridge of the posterior bullar wall.
To achieve this, we introduce a curved seeker along the lateral surface
of the middle turbinate, back toward the basal lamella. We gently pass
the seeker into the retrobullar space between the basal lamella and the
posterior bullar wall. With careful manipulation, the seeker tip can be
seen as it passes through the natural ostium of the bulla (figure 4).
The seeker is then pulled back toward the surgeon to break the
intervening bridge. A microdebrider can then effectively remove the
remnants of the broken tissue bridge.

In conclusion, sinus surgery can be very successful if physiologic
pathways of mucociliary clearance are reestablished. The sinus surgeon
should be meticulous in connecting any accessory or surgically created
drainage pathways with the natural ostia. Although recirculation
following anterior ethmoidectomy is purely hypothetical at this point,
its existence is anatomically intuitive. Ethmoid recirculation might
account for some cases of persistent sinus disease and symptoms despite
an otherwise satisfactory anterior ethmoidectomy. The technique we have
described is fairly simple and adds minimal time to the length of the
surgical procedure.

References

(1.) Citardi MJ, Sillers MJ. The management of chronic rhinosinusitis
after failed sinus surgery. International Online Journal of
Otorhinolaryngology--Head and Neck Surgery 1998;1:1-4.

(2.) Stammberger HR. Functional Endoscopic Sinus Surgery. The
Messerklinger Technique. Philadelphia: B.C. Decker, 1991:17-37.

(3.) Yanagisawa E, Yanagisawa K. Endoscopic view of recirculation
phenomenon of the maxillary sinus. Ear Nose Throat J 1997;76:196-8.

(4.) Chung SK, Dhong HJ, Na DG. Mucus circulation between accessory
ostium and natural ostium of maxillary sinus. J Laryngol Otol
1999;113:865-7.

(5.) Kennedy D, Shanlan H. Reevaluation of maxillary sinus surgery:
Experimental study in rabbits, Ann Otol Rhinol Laryngol 1989;98:901-6.

(6.) Matthews BL, Burke AJ. Recirculation of mucus via accessory ostia
causing chronic maxillary sinus disease. Otolaryngol Head Neck Surg
1997;117:422-3.

(7.) Hollinshead WH. Anatomy for Surgeons. Vol. 1: The Head and Neck.
3rd ed. Philadelphia: Harper and Row, 1982:261-3.

(8.) Coleman JR, Jr., Duncavage JA. Extended middle meatal antrostomy:
The treatment of circular flow. Laryngoscope 1996;106:1214-7.

(9.) Yanagisawa E, Weaver EM. Endoscopic view of the recirculation
phenomenon of sphenoid sinus drainage, Ear Nose Throat J 1996;75:68-70.

(10.) Waguespack R. Mucociliary clearance patterns following endoscopic
sinus surgery. Laryngoscope 1995;105(7 Pt 2 Suppl 71):1-40.

From the Department of Otolaryngology, MetroHealth Medical Center,
Cleveland, and the School of Medicine, Case Western Reserve University,
Cleveland.

Reprint requests: Steve Houser, MD, Department of Otolaryngology,
MetroHealth Medical Center, 2500 MetroHealth Dr., Cleveland, OH
44109-1998. Phone: (216) 778-3453; tax: (216) 778-7868; e-mail:
shouser@metrohealth.org

COPYRIGHT 2003 Medquest Communications, LLC in association with The Gale
Group and LookSmart.
COPYRIGHT 2003 Gale Group

http://www.findarticles.com/cf_dls/m0BUM/1_82/97754546/p1/article.jhtml

-- Steven L.

When you say you have done "everything you know," have you investigated
whether you might have even a mild borderline immunodeficiency?

The immune system is highly complex.  It is quite common to have a
deficiency in just those components of it that deal with respiratory
infections only.

"Any patients with chronic sinusitis, which is poorly responsive to
treatment, should have an extensive immunological evaluation including
immunoglobulin levels, possible IgG subtypes, and antibody testing.
Pneumococcal, diphtheria, and tetanus antibodies should be
tested before and after Pneumovax and diphtheria/tetanus immunizations.
Evaluation should be done by an immunologist familiar with
testing as results can be difficult to interpret. Briefly, 12 different
subtypes of the pneumococcal antigen should ideally be tested with an
adequate rise in the antibody titer to determine that the patient has
responded to the vaccine. In cases where an immunodeficiency is
found, monthly immunoglobulin (IVIG) therapy may need to be initiated.
Selected patients may occasionally warrant IVIG despite
normal antibody levels. Such patients must be selectively chosen by
experienced clinicians, as IVIG is extremely costly."

http://www.sinuses.com/search_site.cgi?fname=postsurg.htm&db=s&skw=immunoglobuli
n&method=and#link

***Another and simpler set of challenges that some immunologists use, is
to use just the pneumovax immunization and a special vaccine consisting
of killed Hemophilus Influenzae bacteria--this has to be specially ordered.

-- Steven L.