Letter to the Editor: Transsphenoidal surgery for nonfunctioning adenomas

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TO THE EDITOR: We read with great interest the recent article by Pledger et al.4 comparing postoperative sinonasal quality of life (QOL) in adult patients surveyed after undergoing microscopic sublabial transsphenoidal surgery (n = 33) or endoscopic endonasal transsphenoidal surgery (n = 46) for pituitary adenomas (Pledger CL, Elzoghby MA, Oldfield EH, et al: Prospective comparison of sinonasal outcomes after microscopic sublabial or endoscopic endonasal transsphenoidal surgery for nonfunctioning pituitary adenomas. J Neurosurg [epub ahead of print December 11, 2015. DOI: 10.3171/2015.6.JNS142695]). Their study addresses the important topic of patients' perceptions of their own recovery from

TO THE EDITOR: We read with great interest the recent article by Pledger et al.4 comparing postoperative sinonasal quality of life (QOL) in adult patients surveyed after undergoing microscopic sublabial transsphenoidal surgery (n = 33) or endoscopic endonasal transsphenoidal surgery (n = 46) for pituitary adenomas (Pledger CL, Elzoghby MA, Oldfield EH, et al: Prospective comparison of sinonasal outcomes after microscopic sublabial or endoscopic endonasal transsphenoidal surgery for nonfunctioning pituitary adenomas. J Neurosurg [epub ahead of print December 11, 2015. DOI: 10.3171/2015.6.JNS142695]). Their study addresses the important topic of patients' perceptions of their own recovery from surgery, which supplements the objective end points that surgeons tend to study. Indeed, nasal morbidity is a primary source of postoperative morbidity in such patients.

This single-center study examined 2 common transsphenoidal approaches. Each approach was performed by a single surgeon. A third commonly performed variation is the microscopic direct endonasal approach, which was not studied by Pledger et al. As surgeons who have performed all 3 approaches at some point in our careers, we have found that the sublabial approach is the most invasive of these 3 approaches because it requires a sublabial incision and extensive dissection of the nasal septal mucosa. However, it is notable that late sinonasal outcomes (i.e., at 1-year follow-up) in the study by Pledger et al. were similar for the 2 approaches, although short-term (i.e., at 24–48 hours, 2 weeks, and 8 weeks) sinonasal outcomes favored the endoscopic approach. This similarity in outcomes illustrates the robust capacity of the sinonasal cavity to heal after surgery.

We recently completed a collaborative multicenter prospective study (Rhinological Outcomes in Endonasal Pituitary Surgery [clinical trial no. NCT01504399, clinicaltrials.gov]) examining QOL in patients undergoing either the direct microscopic approach or the endonasal endoscopic approach.1 This study enrolled more than 200 patients, included baseline and longitudinal data for 6 months, and had greater than 90% patient follow-up. The large sample size and good follow-up increased the power of the study compared to that of the current study by Pledger et al. We also examined the predictors of sinonasal QOL in the patients in our cohort who underwent endoscopic surgery.2 We learned that patients who underwent an endoscopic approach had a slight QOL advantage at 3 months, but we found no difference at later (e.g., 6-month) follow-up. In addition, sinonasal QOL was a strong predictor of overall QOL and recovery. This association reinforces the notion that in the early postoperative period, sinonasal QOL is closely correlated with how patients feel about their overall recovery. We also learned, as in the study by Pledger et al., that there is an initial worsening of sinonasal symptoms after the surgical procedure, but that patients typically recover by approximately 3 months. This pattern of initial worsening and recovery is now well documented.

Through the works of Pledger et al., those of our team, and those of several other groups cited in the article by Pledger et al., the predictors of sinonasal QOL are becoming clearer. These predictors include not only the surgical visualization method, but also the age and sex of the patient, treatment of the middle turbinate, use of the expanded endonasal approach, use of absorbable nasal packing, use of a septal flap, and development of postoperative sinusitis. Increased understanding of these factors will help surgeons to better counsel their patients, and also will improve surgical techniques to optimize QOL. Last, additional QOL scales with improved validity for this specific patient population continue to be developed.3

References

  • 1

    Little ASKelly DFMilligan JGriffiths CPrevedello DMCarrau RL: Comparison of sinonasal quality of life and health status in patients undergoing microscopic and endoscopic transsphenoidal surgery for pituitary lesions: a prospective cohort study. J Neurosurg 123:7998072015

  • 2

    Little ASKelly DMilligan JGriffiths CPrevedello DMCarrau RL: Predictors of sinonasal quality of life and nasal morbidity after fully endoscopic transsphenoidal surgery. J Neurosurg 122:145814652015

  • 3

    Little ASKelly DMilligan JGriffiths CRosseau GPrevedello DM: Prospective validation of a patient-reported nasal quality-of-life tool for endonasal skull base surgery: The Anterior Skull Base Nasal Inventory-12. J Neurosurg 119:106810742013

  • 4

    Pledger CLElzoghby MAOldfield EHPayne SCJane JA Jr: Prospective comparison of sinonasal outcomes after microscopic sublabial or endoscopic endonasal transsphenoidal surgery for nonfunctioning pituitary adenomas. J Neurosurg [epub ahead of print December 11 2015. DOI: 10.3171/20156.JNS142695]

Disclosures

The authors report no conflict of interest.

Response

We thank Drs. Little, Kelly, and Barkhoudarian for their thoughtful comments, and we agree with their statements regarding patient recovery following transsphenoidal surgery. Patients undergoing endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas appear to recover more quickly than those who undergo microscopic techniques. However, long-term sinonasal recovery was not found to differ significantly between approaches. Because the lasting sinonasal results appear similar, we continue to advocate that surgeons choose the visualization tool (microscope or endoscope) based on their experience and ability to effectively remove the tumor.

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Article Information

INCLUDE WHEN CITING Published online March 18, 2016; DOI: 10.3171/2015.12.JNS152965.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Little ASKelly DFMilligan JGriffiths CPrevedello DMCarrau RL: Comparison of sinonasal quality of life and health status in patients undergoing microscopic and endoscopic transsphenoidal surgery for pituitary lesions: a prospective cohort study. J Neurosurg 123:7998072015

2

Little ASKelly DMilligan JGriffiths CPrevedello DMCarrau RL: Predictors of sinonasal quality of life and nasal morbidity after fully endoscopic transsphenoidal surgery. J Neurosurg 122:145814652015

3

Little ASKelly DMilligan JGriffiths CRosseau GPrevedello DM: Prospective validation of a patient-reported nasal quality-of-life tool for endonasal skull base surgery: The Anterior Skull Base Nasal Inventory-12. J Neurosurg 119:106810742013

4

Pledger CLElzoghby MAOldfield EHPayne SCJane JA Jr: Prospective comparison of sinonasal outcomes after microscopic sublabial or endoscopic endonasal transsphenoidal surgery for nonfunctioning pituitary adenomas. J Neurosurg [epub ahead of print December 11 2015. DOI: 10.3171/20156.JNS142695]

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