Repercussion of Preservation of Bilateral Middle Turbinates during Pituitary Surgery on Maxillary, Ethmoid, and Frontal Sinuses

Objective To evaluate and describe postoperative sinus comorbidities in patients undergoing pituitary surgery via an endoscopic endonasal approach with bilateral middle turbinate preservation.

Background The choice whether to resect the middle turbinate for an endoscopic endonasal approach for pituitary adenoma resection has been a point of controversy, as some argue resection allows for improved surgical field of view and decreased chances of postoperative sinus comorbidities. Conversely, others argue preservation does not affect surgical view and improves nasal function without impacting sinus health. We aim to evaluate patient postoperative scans for evidence of sinusitis in correlation with their SNOT-22 scores to assess whether middle turbinate preservation increases radiologic and subjective findings of sinusitis.

Study Design Retrospective cohort study at a tertiary academic center.

Methods Fifty patients in a 1.5-year period from December 2015 to June 2017 who underwent endoscopic endonasal resection of pituitary adenomas with bilateral middle turbinate preservation were retrospectively reviewed. Both the inpatient and outpatient EMRs were reviewed for each patient's postoperative course, SNOT-22 scores, and nasal endoscopy scores. MRI surveillance scans were reviewed, obtained at 3, 12, or 24 months after surgery according to our departmental protocol. These scans were collected and reviewed for postoperative sinus complications including sinus inflammation as seen via T2 signal enhancement and other sinus complications.

Results A total of 146 scans were reviewed for our patient population; four patients did not have a 12-month scan. Thirty-four of 50 patients had no evidence of enhancement, or sinus inflammation within the maxillary, ethmoid, or frontal sinuses on preoperative scan; of these, five patients had one to three sinuses develop T2 enhancement. This did not correlate with the patients in clinic endoscopy findings, and did not correlate with worsening SNOT-22 score. The remaining 16 patients demonstrated some enhancement and evidence of sinus inflammation on preoperative MRI; 9 had no change in image findings, 6 demonstrated complete resolution, and 1 patient showed more T2 enhancement with no correlation to endoscopy findings nor SNOT-22 score as seen in clinical follow-up. There was no evidence of other associated sinus complication.

Conclusion Our study demonstrates that middle turbinate preservation for endoscopic endonasal resection of pituitary adenomas, regardless of use of skull base reconstruction, shows no increase in sinus comorbidities, without compromise of surgical access. Middle turbinates and normal sinus anatomy are visualized for the anterior ethmoid, maxillary, and frontal sinus cavities, with no significant incidence of sinusitis or associated complications as seen on MRI, and endoscopy scores. Functional benefits of turbinate preservation need to be studied, but correlate with overall reduction of SNOT-22 scores.