Evolution of Sinonasal Symptoms Following Transnasal Endoscopic Skull Base Surgery Using a Pedicled Nasoseptal Mucosal Flap

Abstract

Transnasal endoscopic surgery of the anterior skull base has been increasingly used by skull base surgeons in recent years. A dual-surgeon approach, with an otolaryngologist and neurosurgeon operating together, provides excellent visualization and operative maneuverability. To counter cerebrospinal fluid (CSF) leaks, pedicled nasoseptal mucosal flaps (PNSMFs) have been proposed to augment the closure. Sinonasal complaints are expected sequelae of this technique. We describe the evolution of sinonasal symptoms in a series of patients who have undergone this type of surgery, as documented by the Sinonasal Outcomes Test (SNOT-20), a widely used disease-specific, health-related quality-of-life measure for rhinosinusitis. From January 2008 through May 2009, 85 adult patients underwent transnasal endoscopic surgery using a PNSMF for a variety of diseases. The most common diagnosis was pituitary tumor, but others included Rathke's cleft cyst, meningiomas, chordomas, and hypothalamic lesions. Postoperative complications were rare. Six patients (7%) had CSF leaks requiring reoperation. Significant postoperative nasal bleeding occurred in one patient, and this was successfully managed in the emergency room with cautery and packing. All patients performed daily nasal saline irrigations at home and returned at regular intervals for debridement of their sinus cavities. They filled out the SNOT-20 at regular intervals after surgery, describing their postoperative nasal symptoms. The vast majority did not have significant sinus disease preoperatively. Sinonasal complaints were universal during the first month and included crusting, congestion, rhinorrhea, and sinus pressure, but they gradually diminished over the ensuing months. Scores for the symptoms of sneezing, postnasal discharge, runny nose, and thick nasal discharge showed significant improvement over time. Scores for most other sinonasal symptoms showed improvement over time, but did not reach statistical significance. All patients had a temporary loss of smell, but this returned to near normal levels within 3–6 months.