Our Experience of the Expanded Endoscopic Endonasal Approach to Suprasellar Tumors and Pathology

Surgical resection remains the main therapeutic treatment for Suprasellar tumors. Due to their proximity to important neurovascular structures, surgical resection poses significant challenges and morbidity. Expanded endoscopic endonasal approaches (EEEA) have been developed and utilized over the years. The development of high-definition cameras and angled-scopes alongside sophisticated image-guidance equipment has improved surgical efficiency; making the endoscopic trans-nasal corridor a popular approach for such tumors. Although this technique carries advantages over the more traditional transcranial approach, it exposes patients to the serious risk of a CSF leak and potential nasal morbidity which could be detrimental to their quality of life. The most recent reported rates of CSF leak for EEEA approach to anterior meningiomas and craniopharyngioma in adults are in the region of 4–5%. These are higher in the pediatric population. In the United Kingdom, more centers are performing endoscopic skull base procedures jointly with ENT. This aims to allow optimal access for resection while reducing nasal morbidity and CSF leaks via well-vascularized, pedicled flaps and multi-layered reconstruction. We also provide extensive postoperative sinonasal aftercare. We share our series from a newly developed endoscopic skull base department in the UK; focusing on our CSF leak rates and SNOT-22 scores for our EEEA to the suprasellar.

Methods: Data were collected over a period from September 2020 until February 2024. All patients who underwent an EEEA for suprasellar tumor resections and pathologies were identified and included in the case series. Clinical notes were reviewed for preoperative and postoperative SNOT-22 scores, incidents of CSF leak postoperatively, and patient demographics.

Results: Thirty-four patients were identified who underwent surgery during this period; of which 4 patients were pediatric. 73.5% of patients were female with an average age of 9 in the pediatric group, and 53 in the adults; ages ranged from 5 to 76. The average adult BMI was 29.1. Thirteen patients (38%) underwent resection of craniopharyngiomas, 7 patients (21%) had tuberculum sella meningiomas (TSM) and the remainder had a variety of other pathologies requiring a suprasellar approach. Our overall adult CSF leak rate was 3.33%: only 1 adult patient was identified to have a post-operative CSF leak with no pediatric patients leaked. The patient with a CSF leak had undergone an EEEA and resection of TSM with nasoseptal flap and fascia lata graft. Pre-operative SNOT-22 scores were recorded for 21 patients: with an average score of 20. Of the 19 patients who also had postoperative SNOT-22 scores completed, 11 patients (58%) had at least a return to baseline if not improvement in their postoperative score.

Discussion: Our case series demonstrates the successful implementation of our approach to the EEEA. With careful case selection and choice of surgical and reconstructive techniques, a low CSF leak rate was achieved, irrespective of patient demographics or primary pathology. Over 50% of patients had a return or improvement in their SNOT-22 scores post-operatively suggesting an adequate recovery in nasal symptoms associated with our techniques. However, further collection of SNOT-22 scores and increased cases will continue to improve our database.

Publication History

Article published online:
07 February 2025