Added Sinonasal Morbidity of Transpterygoid Approach versus Transsphenoidal Approach: A Case-Controlled Analysis

Abstract

Background The transpterygoid approach is often used alongside the transsphenoidal approach in endoscopic endonasal skull base surgery to access lateral skull base regions. This study investigates the sinonasal morbidity associated with this combined approach.

Methods We conducted a retrospective analysis of 70 adult patients who underwent either transsphenoidal (TS) or transsphenoidal plus transpterygoid (TS + TP) approaches at a tertiary academic hospital from 2018 to 2023. Sinonasal quality of life was measured using the Sinonasal Outcome Test (SNOT-22) at preoperative, 2-week, 6-week, and 12-week postoperative evaluations.

Results Both cohorts exhibited a significant increase in SNOT-22 scores at 2 weeks postoperatively (TS: mean increase of 8.5, p = 0.020; TS + TP: mean increase of 12.3, p < 0.001), which normalized by 6 and 12 weeks (TS: p = 0.587 and p = 0.987, respectively; TS + TP: p = 0.378 and p = 0.220, respectively). There were no statistically significant differences in sinonasal morbidity between the TS and TS + TP cohorts at any time point. Middle turbinate (MT) sacrifice was associated with higher SNOT-22 scores (B = 12.559, p = 0.035), indicating worsened sinonasal outcomes.

Conclusion The transpterygoid approach, when added to the transsphenoidal approach, does not increase long-term sinonasal morbidity. This suggests that the combined approach is a viable option for achieving broader surgical exposure without compromising sinonasal quality of life in the long term. Further studies with extended follow-up are needed to confirm these findings and explore additional quality of life metrics.

Keywords

transpterygoid approach - transsphenoidal approach - sinonasal morbidity - endoscopic endonasal skull base surgery - SNOT-22 - sinonasal quality of life - skull base surgery - middle turbinate sacrifice - sinonasal outcomes - retrospective analysis

Previous Presentation

Accepted for poster presentation at American Rhinologic Society 2024 COSM on May 17, 2024 in Chicago, Illinois.

Publication History

Received: 19 July 2024

Accepted: 05 January 2025

Accepted Manuscript online:
06 January 2025

Article published online:
24 January 2025

• References

• 1 Hofstetter CP, Singh A, Anand VK, Kacker A, Schwartz TH. The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave. J Neurosurg 2010; 113 (05) 967-974
• 2 Finger G, Gun R, Wu KC, Carrau RL, Prevedello DM. Endoscopic endonasal transpterygoid approach: technical lessons. Oper Neurosurg (Hagerstown) 2023; 25 (05) e272
• 3 Bokhari AR, Davies MA, Diamond T. Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve. Br J Neurosurg 2013; 27 (01) 44-49
• 4 Pinheiro-Neto C, Rowan NR, Celda MP, Mukherjee D, Gompel JJV, Choby G. Optimizing quality of life and minimizing morbidity through nasal preservation in endoscopic skull base surgery: a contemporary review. J Neurol Surg B Skull Base 2022; 83 (06) 602-610
• 5 Feng AL, Wesely NC, Hoehle LP. et al. A validated model for the 22-item Sino-Nasal Outcome Test subdomain structure in chronic rhinosinusitis. Int Forum Allergy Rhinol 2017; 7 (12) 1140-1148
• 6 McCoul ED, Bedrosian JC, Akselrod O, Anand VK, Schwartz TH. Preservation of multidimensional quality of life after endoscopic pituitary adenoma resection. J Neurosurg 2015; 123 (03) 813-820
• 7 Balaker AE, Bergsneider M, Martin NA, Wang MB. Evolution of sinonasal symptoms following endoscopic anterior skull base surgery. Skull Base 2010; 20 (04) 245-251
• 8 Choi JE, Noh YS, Lee KE. et al. Morbidities associated with the endoscopic transnasal transpterygoid approach: focusing on postoperative sequelae. World Neurosurg 2020; 137: e43-e51
• 9 Kennedy DW. Middle turbinate resection: evaluating the issues—should we resect normal middle turbinates?. Arch Otolaryngol Head Neck Surg 1998; 124 (01) 107
• 10 Nyquist GG, Anand VK, Brown S, Singh A, Tabaee A, Schwartz TH. Middle turbinate preservation in endoscopic transsphenoidal surgery of the anterior skull base. Skull Base 2010; 20 (05) 343-347
• 11 Shah J, Tang D, Grafmiller K, Cappello ZJ, Roxbury C, Sindwani R. Using the middle turbinate to protect the skull base in endoscopic transsphenoidal surgery: a cadaver study. Am J Rhinol Allergy 2021; 35 (01) 59-63
• 12 Maza G, Li C, Krebs JP. et al. Computational fluid dynamics after endoscopic endonasal skull base surgery-possible empty nose syndrome in the context of middle turbinate resection. Int Forum Allergy Rhinol 2019; 9 (02) 204-211
• 13 Barham HP, Gould EA, Ramakrishnan VR. Swing technique for middle turbinate preservation in expanded endonasal skull base approaches. Int Forum Allergy Rhinol 2014; 4 (07) 583-586
• 14 Renteria A, Levi L, Silva B. et al. Outcomes of the middle turbinate swing technique during the expanded endonasal approach (EEA): a tertiary center experience. J Neurol Surg B Skull Base 2024; 85 (S 01): S031