Preoperative Considerations for Septoplasty Before Endoscopic Transsphenoidal Pituitary Resection

Introduction: The endoscopic transsphenoidal approach is a minimally invasive technique widely utilized for access in the resection of anterior skull base masses. This access may be limited by anatomical variations within the nasal cavity, such as septal deviation, which can pose challenges during the surgical approach. A deviated septum can obstruct access to the skull base, potentially leading to increased operative time and difficulty with restricted view or instrumentation. Prior studies have noted that concomitant septoplasty at the time of transsphenoidal surgery can optimize the surgical field and enhance visualization and access. However, literature specifically analyzing preoperative factors predictive of concomitant septoplasty during endoscopic transsphenoidal surgery is limited. Computerized tomography (CT) scan measurements predicting the need for septoplasty can be a useful tool in surgical decision-making and patient counseling.

This study evaluates objective preoperative CT scan parameters to determine if any of these measurements are associated with increased rates of concurrent septoplasty in endoscopic transsphenoidal surgeries.

Methods: We performed a retrospective chart review of 427 patients who underwent transsphenoidal surgery from November 2016 to July 2022 at a single institution tertiary hospital. Patient demographics, tumor pathology, presence of intraoperative septoplasty at the time of transsphenoidal approach and total operative time were analyzed. Preoperative CT scans were evaluated for minimum distance from septum to middle turbinate, maximum angle of septal deviation, angle of internal nasal valve, and cross-sectional area at the inferior and middle turbinates. Patients with a history of prior septoplasty or sinonasal surgery were excluded. Patients with preoperative CT scans that lacked adequate coronal and axial views to measure the aforementioned CT variables were also excluded. A total of 269 patients met inclusion criteria. Patients were then stratified into those who underwent intraoperative septoplasty and those who did not. Data between the two groups were compared using student’s t-test with an alpha value of 0.05 for significance.

Results: A total of 21 patients out of the 269 with analyzed CT images underwent concurrent septoplasty (7.8%). In a univariate analysis, septoplasty was strongly associated with the angle of maximal septal deviation (p = 0.0000006), measured between the crista galli and the most lateral portion of the septum. In a multivariable logistic regression, the angle of the internal nasal valve (p = 0.016), the cross-sectional area at the head of the right inferior turbinate (p = 0.0097), and the angle of maximal septal deviation (p = 0.0000049). were all significantly correlated with the need for intraoperative septoplasty. Cases that required septoplasty took significantly longer (p = 0.023), and added an average of 35 minutes to the case.

Conclusion: This is the first study to identify imaging parameters that are correlated with concurrent septoplasty during an endoscopic transsphenoidal approach. Future prospective studies will aim to determine whether a combination of these parameters can predict septoplasty in a validated way.

Publication History

Article published online:
05 February 2024