Decision-making for choosing when to perform revision endoscopic sinus surgery is increasingly complicated given the availability of new medical treatments such as innovative methods for steroid delivery and biologics targeting inflammation. Through case-based examples, this session shows how the use of available data affects decision-making for revision endoscopic sinus surgery. We will address anatomic factors—including paranasal sinus mucoceles, residual uncinate process, maxillary sinus recirculation, middle turbinate lateralization, frontal and sphenoid ostial stenosis, and frontal recess neo-osteogenesis—seen on sinonasal imaging and endoscopy that suggest revision endoscopic sinus surgery success. The comprehensive otolaryngologist, advanced practice provider, and otolaryngologist-in-training will learn to utilize patient characteristics and anatomic findings to inform the decision for revision endoscopic sinus surgery versus more intensive medical management. The role of biologics in the management of the refractory sinus patient will be specifically discussed. Cases will illustrate the evidence for treating nasal polyposis with topical medications versus biologics versus revision endoscopic sinus surgery. We will also discuss tools of revision surgery, including image guidance, augmented reality, balloon sinus dilation, and powered instrumentation. Surgical techniques and maneuvers for addressing common anatomic problems seen in the refractory chronic rhinosinusitis patient are described.