Sinonasal Quality-of-Life Outcomes after Endoscopic Endonasal Transsphenoidal Surgery with Free Mucosal Graft Reconstruction

Objectives: The literature suggests that after endoscopic endonasal transphenoidal surgery (EETS) without formal reconstruction of the sella, sinonasal quality of life (QOL) recovers by 3 to 6 months postoperatively. An option for sellar reconstruction, in the absence of a significant intraoperative cerebrospinal fluid (CSF) leak, is a free mucosal graft (FMG) taken from the posterior septum. In this study we analyze sinonasal quality of life (QOL) outcomes in patients undergoing EETS with FMG reconstruction.

Design: Present study is a retrospective review.

Setting: This study was conducted at a tertiary care academic center.

Participants: Patients undergoing sellar reconstruction with a FMG after EETS from 2013 to 2018.

Main Outcome Measures: Patient, tumor, and surgical factors were included, along with postoperative complications. Patients completed sinonasal outcome test 22 (SNOT-22) scores during the preoperative visit, as well as first two postoperative visits. SNOT-22 scores were further categorized into five domains, as previously described in the literature.

Results: A total of 115 patients underwent sellar reconstruction with a FMG during EETS. Most surgeries were performed for pituitary adenomas (82%). Among the patients, 104 (90%) had no intraoperative CSF leak, while 11 patients (10%) had a low-grade intraoperative CSF leak. There was one patient (<1%) who developed a postoperative CSF leak. Three patients (3%) developed epistaxis, requiring an emergency room visit or operative intervention. The median time from surgery until the first postoperative visit was 13 days (95% CI: 6–22). The median time from surgery until the second postoperative visit was 57 days (95% CI: 15–126). The average preoperative SNOT-22 score was 17.5; first postoperative SNOT-22 score was 32.9; and second postoperative SNOT-22 score was 21.3 ([Fig. 1]), suggesting near normalization of sinonasal QOL by the second postoperative visit. After categorizing by SNOT-22 domains, there were significant improvements in SNOT-22 scores for almost all domains, including domain 1 (rhinologic symptoms), domain 2 (extra-nasal rhinologic symptoms), domain 3 (ear/facial Symptoms), and domain 4 (sleep dysfunction) symptoms ([Fig. 2]).

Conclusion: During EETS, FMG reconstruction of sellar defects is an effective and well-tolerated option for patients without significant intraoperative CSF leaks. Patients demonstrated early recovery of baseline sinonasal QOL by 2 months postoperatively.

Fig. 1 Comparison of average preoperative and first two postoperative visit SNOT-22 scores.

Fig. 2 Comparison of individualized preoperative and first two postoperative visit SNOT-22 scores