Commentary

Dr. El-Banhawy and colleagues present a well-executed and tight article that should be of interest to readers of Skull Base: An Interdisciplinary Approach from the perspective of surgical technique, particularly as we continue to explore the capabilities and limitations of endoscopic techniques for advancing and augmenting our approach to skull base pathology. The advantages of endoscopy for minimizing the invasiveness of an approach, for maximizing patient comfort, for widening the field of vision, and for looking around corners are clear. The disadvantages associated with the loss of three-dimensional depth perception, periodic obscuration of the view, piecemeal resection of tumors, and potentially poor vascular control mean that careful patient selection and continued refinement of instrumentation are critical to the continued popularity of the endoscopic technique. In our own practice, endoscopy has been most helpful for the treatment of benign tumors of the sella turcica. Indeed, since 1998 we have needed to convert only one case to a microsurgical approach due to restricted endoscopic access to the nares and visualization in a very small patient with Cushing's disease.

Several points must be emphasized. First, hypotensive general anesthesia should be unnecessary for endoscopy of the sella turcica and sphenoid sinus and represents a potentially avoidable anesthetic risk. Second, frameless stereotactic intraoperative navigation is now routinely available and provides a much more three-dimensional and useful imaging guide than traditional fluoroscopy. Third, the rate of septoplasty seems unusually high. In our experience, it has not been a routine requirement for this approach. Fourth, if no mucosal flaps are raised, nasal packing can be avoided to the applause of grateful patients everywhere. Finally, in all studies of surgical outcome of secretory pituitary adenomas, the hormone levels considered to be “cures” must be reported. Furthermore, these levels must be reported immediately after surgery as well as at the most recent follow-up with the length of follow-up stated. Standards for hormone reporting have been established and must be adhered to. This article did not define the hormonal level for cure or the length of hormonal follow-up. Furthermore, growth hormone (GH) levels alone are insufficient to evaluate acromegaly because insulin-like growth factor (IGF)-1 (somatomedin C) levels can remain abnormally elevated in the setting of “high normal” GH levels.