Using the Nose-Perf Scale for Symptom Assessment After Transsphenoidal Approach to the Pituitary Gland

Background: The transsphenoidal endonasal approach to the pituitary gland (TSEP) usually entails creating a wide posterior septectomy and a posterosuperior septal defect. The NOSE-Perf Scale (NPerfS) is a 12-item patient-reported outcome measure (PROM) (scored 0 to 48; higher is worse) recently validated for reporting patient-perceived impact of septal perforations. The minimal clinically important difference (MCID) for the NPerfS is 3.1 (standard deviation-based method) and 4.8 (standard error of mean [SEM]-based method). The long-term patient-perceived morbidity of posterior septectomies has not been studied. We conducted a cross-sectional observational study of TSEP subjects using the NPerfS to assess symptoms.

Methods: IRB approval was obtained. Subjects who underwent TSEP for pituitary adenoma resection at Mayo Clinic Arizona between January 2022 and 2024 were invited to participate. Subjects with less than 3 months of follow-up were excluded. Subject groups used to validate the NperfS were used for comparison and were composed of three other cohorts: one with 22 healthy subjects (control), one with 117 subjects with symptomatic septal perforation, and one with the same 117 subjects after they underwent septal perforation surgical repair. For enrolled TSEP patients, the NPerfS was administered via a phone survey. Data was reported on age, gender, follow-up duration, body mass index, smoking status, SNOT-22 scores, concomitant septoplasty, intraoperative CSF leak, nasoseptal flap harvest, sinonasal comorbidities, topical nasal medications, nasal packing, and nasal splints.

Results: Twenty-five TSEP subjects participated. Total NPerfS was 7 (IQR 2–10) for the TSEP posterior septectomy group, 1 (IQR 0–3) for healthy controls, 24 (IQR 18–33) for symptomatic perforation controls, and 7 (IQR 3–14) for perforation repair controls. There was no significant difference between posterior septectomy and perforation repair groups (p = 1). Scores were significantly lower for healthy controls (p = 0.037) and higher for symptomatic perforation (p < 0.001) when compared with posterior septectomy group. Three subjects were outliers in the posterior septectomy group, with NPerfS of 23, 26, and 27. The first had undergone a pre-TSEP and had previous anterior septal perforation, the second had pre-TSEP transoral resection of pituitary adenoma while the third was an active smoker with persistent crusting 10 months post-TSEP. The first two subjects had undergone CSF leak repair with nasoseptal flap while the 3rd did not have CSF leak or septal flap harvest. Finally, no significant differences in total NPerfS score were noted between those with (11/25) or without (14/25) nasoseptal flap harvest in the TSEP group (p = 0.13).

Conclusion: Posterior septectomy morbidity appears to be low as assessed by the NperfS. The residual symptomatic burden was no worse than in patients who underwent septal perforation surgical repair; however, scores were worse than in healthy subjects without septal perforations. Nasoseptal flap harvest was not significantly associated with additional long-term morbidity in TSEP patients. Expectation adjustments that a posterior septectomy might be associated with modest long-term symptomatic burden can be helpful for shared decision-making. Smoking status and presence of prior perforations may detrimentally impact NperfS, while the performance of pituitary surgery itself may have impacted scores. Larger prospective studies can further characterize morbidity from posterior septectomy.