Modifications to the Endoscopic Approach for Anterior Skull Base Lesions Improve Postoperative Sinonasal Symptoms

Background: Our institution has previously shown that patients experience significant postoperative sinonasal symptoms after endoscopic transnasal transsphenoidal skull base surgery. On the Sinonasal Outcomes Test (SNOT)-20 questionnaire, postoperative scores significantly worsened for need to blow nose, sneezing, runny nose, postnasal discharge, thick nasal secretions, and facial pain and pressure. Patients’ complaints were worse in the first 3 months postoperatively, but then returned to near baseline by 6-9 months. Since this initial study, we have modified our surgical technique during the endoscopic approach in an attempt to decrease postoperative sinonasal complaints. We now rarely resect the middle turbinate, do not routinely perform a maxillary antrostomy, and have decreased the use of pedicled nasoseptal flaps for skull base reconstruction to minimize the disruption of normal sinonasal physiology. Objective: To determine if our surgical modifications have resulted in decreased postoperative sinonasal morbidity in patients undergoing endoscopic transnasal transsphenoidal skull base surgery. Setting: Tertiary academic medical center. Patients and Methods: Eighty-six consecutive patients who underwent endoscopic transnasal transsphenoidal skull base surgery from August 2011 to August 2012 were included in this study. The main outcome measure was the SNOT-20 survey scores preoperatively and at three postoperative time points. An ordinal logistic regression model was used to analyze the data. The mean changes from baseline in each item of the questionnaire were compared for each postoperative time point, which included early (36-101 days), mid (106-190 days), and late (202-300 days) periods. Additionally, the SNOT-20 scores of this current cohort were compared with the scores of our previous study’s cohort of 69 patients who routinely had partial middle turbinectomy, maxillary antrostomy, and nasoseptal flap performed. Results: All patients will experience sinonasal symptoms following transnasal endoscopic skull base surgery; however, our results suggest that the surgical modifications result in significantly less patient complaints. In this current cohort, the only worse scores during the early postoperative period were sneezing ( P = 0.004), postnasal discharge ( P = 0.000), and waking up at night ( P = 0.05). Only postnasal discharge remained significant during the mid postoperative period ( P = 0.004). Compared with the previous cohort, this new population of patients had significantly better scores for runny nose ( P = 0.27), thick nasal discharge ( P < 0.000), dizziness ( P = 0.012), and facial pain and pressure ( P = 0.034) during the early postoperative period. Additionally, patients had improved scores for runny nose ( P = 0.044) and ear fullness ( P = 0.025) during the mid postoperative period. Conclusion: Preserving normal sinonasal physiology during transnasal transsphenoidal endoscopic surgery by limiting middle turbinate resections, avoiding unnecessary maxillary antrostomies, and reducing the use of nasoseptal flaps results in less sinonasal morbidity and more rapid recovery during the postoperative period.