Original Article
Clinical Significance of Nasal Pathologies in Transnasal Transsphenoidal Pituitary
Surgery
Tolga Gediz1 and Erdem Özer Gür2
- BACKGROUND: We evaluated the frequency of nasal
pathologies and the significance of surgical access to the
sellar region in patients who underwent an operation for
sellar mass using the endonasal and microscopic trans-
sphenoidal approaches.
- METHODS: We retrospectively evaluated all patients
who underwent surgery for pituitary macroadenoma using
microscopic (n [ 78) and endonasal (n [ 20) trans-
sphenoidal approaches. Patients’ epicrisis, preoperative,
and postoperative imaging as well as their operative notes
were reviewed. Nasal pathologies and surgeries performed
before or during the pituitary surgery were also docu-
mented. All endonasal surgeries were binostril and per-
formed jointly by an ear, nose, and throat specialist and
neurosurgeon. To determine the feasibility of endonasal
and microscopic approaches, we developed an algorithm
using the septum deviation classifications to determine the
need for septoplasty.
- RESULTS: The most common nasal pathology was
septum deviation (n [ 17; 17.3%). Of the other nasal pa-
thologies, 6 cases (6%) were chronic sinusitis and 2 were
(2.1%) middle turbinate bullosa.
- CONCLUSIONS: The preoperative evaluation of patients
undergoing endonasal transsphenoidal surgery by an ear,
nose, and throat surgeon allows for the detection and
treatment of nasal pathologies that may lead to serious
perioperative and postoperative complications. Evaluating
patients with septum deviation using our classification will
Key words
- Endoscopic pituitary surgery
- Nasal pathology
- Septum deviation
Abbreviations and Acronyms
CT: Computed tomography
ENT: Ear, nose, and throat
From the 1Department of Neurosurgery, and 2Department of Otolaryngology (ENT)/Head and
Neck Surgery, Antalya Training and Research Hospital, Antalya, Turkey
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help determine the necessity of preoperative or perioper-
ative septum surgery, depending on the preferred pituitary
surgical method.
INTRODUCTION
S ellar region pathologies are an important segment of
neurosurgery practice. Although these cases can be treated
using cranial, transnasal microscopic, or endonasal ap-
proaches, the transnasal endoscopic approach is the first choice in
many surgical centers. With increasing surgical experience, the
endoscopic approach can be successfully applied to pathologies
that have spread to the skull base. In some cases, nasal pathol-
ogies may complicate surgery and may even prevent access to the
sellar region.
In this study, we retrospectively evaluated the frequency of nasal
pathologies and the importance of surgical access to the sellar
region in patients who underwent an operation for a sellar mass
using the endonasal and microscopic transsphenoidal approaches.
In addition, the importance of cooperation between otolaryn-
gology and neurosurgery was emphasized, and an algorithm was
created for pituitary surgery management.
MATERIAL AND METHODS
We retrospectively evaluated all patients who underwent surgery
for pituitary macroadenoma using microscopic (n ¼ 78) and
endonasal (n ¼ 20) transsphenoidal approaches in our hospital
between January 2018 and January 2021 (n ¼ 98). Patients whose
surgery was performed with the craniotomy approach (n ¼ 12)
were excluded from the study. Patients’ epicrisis, preoperative,
To whom correspondence should be addressed: Tolga Gediz, M.D.
[E-mail: tolgagediz@yahoo.com]
Tolga Gediz and Erdem Özer Gür equally contributed to this manuscript.
Citation: World Neurosurg. (2022) 164:e824-e829.
https://doi.org/10.1016/j.wneu.2022.05.059
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2022 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2022.05.059

TOLGA GEDIZ AND ERDEM ÖZER GÜR
and postoperative imaging (i.e., paranasal sinus computed to-
mography [CT], brain CT, and pituitary magnetic resonance im-
aging) as well as their operative notes were reviewed. Nasal
pathologies (i.e., septum deviation, concha bullosa, nasal polyp,
inferior turbinate hypertrophy, chronic sinusitis with or without
polyp) and surgeries performed before or during the pituitary
surgery were also noted. Preoperative endoscopic examinations
were performed by an ear, nose, and throat (ENT) physician. All
endonasal surgeries were binostril and performed by an ENT
specialist and neurosurgeon together.
For all patients who underwent an endoscopic approach, par-
anasal sinus CT images were evaluated prior to surgery. In patients
with septum deviations detected via CT, the shape of the deviation
was evaluated via the presence of S-shaped or C-shaped deviation
in the same manner as Guyuron’s classification system.1 The
degree of deviation was evaluated according to the relationship
between the deviated septum with the inferior turbinate and
lateral wall, in the same manner as Vidigal et al.2 To determine
the feasibility of endonasal and microscopic approaches, we
developed an algorithm using the septum deviation classification
systems created by Guyuron and Vidigal et al.2 to determine the
need for septoplasty. Using this table to preoperatively evaluate
septum deviation and the appropriate surgical approach,
removal of the deviation prior to the planned surgery or
simultaneous endonasal septoplasty may be considered (Table 1).
RESULTS
Fifty-one (52%) patients were female, and the mean age was
48 years. Thirty-four nasal pathologies were detected in 29 (29.5%)
patients (Table 2). The most common nasal pathology was septum
deviation (n ¼ 17; 17.3%). Of the 17 patients with septum
deviations, 11 and 6 underwent surgery using the microscopic
and endoscopic approach, respectively. Of the septum
deviations, 5 were S-type and 12 were C-type deviations
(Figures 1 and 2). Of the patients with S-type septum deviations,
3 and 2 underwent surgery using the microscopic and
Table 1. Evaluation of Septum Deviation and the Need for
Septoplasty, According to the Surgical Technique in Patients
Who Underwent Pituitary Surgery
Need for Septoplasty
Deviation Type and Endonasal (Four Endonasal (Two
Degree Microscopic Hand) Hand)
S-shaped degree I - -
S-shaped degree II and þ þ
III
C-shaped degree I - -
C-shaped degree II and - þ
III
Degree 1 wide spurs - -
Degree II and III wide - þ
spurs
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ORIGINAL ARTICLE
NASAL PATHOLOGIES IN TRANSNASAL SURGERY
endoscopic approach, respectively. In 2 of the patients with S-
type deviations who underwent surgery using the microscopic
approach, septoplasty was performed 1 month prior to the
operation. Pituitary surgery and septoplasty were performed
simultaneously in the 2 patients with S-type deviations who
underwent surgery using the endoscopic approach. Of the 12
patients with C-type deviations, 8 underwent surgery using the
microscopic approach and 4 underwent surgery using the
endoscopic approach. Preoperative septoplasty was not
performed in any of the patients who underwent microscopic
surgery, and simultaneous septoplasty was performed in 2
patients who underwent endoscopic surgery because of degree
III septum deviation.
Among the other nasal pathologies, 6 patients (6%) had chronic
sinusitis, 3 of which had polyps and 3 of which did not have polyps
(Figure 3). Two patients with chronic sinusitis and polyps were
operated endoscopically with simultaneous endoscopic sinus
surgery, whereas one patient who has chronic sinusitis and
polyps was operated microscopically and endoscopic sinus
surgery was not performed. A total of 2 patients (2.1%) had
middle turbinate bullosa; during endonasal surgery, one patient
underwent an opening of the concha bullosa with resection of
its inferior portion. Hypertrophy of the inferior turbinate was
present in 3 patients (3.2%), and lateralization of the inferior
turbinate was needed to be performed in 2 of these patients
during endonasal surgery. Maxillary sinus mucocele was present
in 2 patients (2.1%) (Figure 4), and there was a mass in the
frontal sinus of one patient (1.1%).
DISCUSSION
Nasal pathologies and variations in the path from the nares to the
base of the sella can complicate all transsphenoidal surgical ap-
proaches; endonasal surgery will be more greatly affected by these
pathologies. The endonasal transsphenoidal approach is now
considered the first choice as a surgical approach to sellar masses
in many clinics around the world.3-5 Although endonasal surgery
was originally only performed by ENT surgeons, nowadays, it can
be performed by neurosurgeons in many neurosurgery clinics.
Many conditions can complicate endonasal sellar surgery; how-
ever, variations and pathologies in the nasal cavity are the most
challenging conditions, especially for a neurosurgeon. These pa-
thologies may make it difficult to perform the surgery and can
sometimes even prevent the surgeon from reaching the sella
endonasally. In our study, 34 nasal pathologies were detected in 29
(29.5%) patients with sellar masses who had undergone an
operation with a pituitary macroadenoma diagnosis. Although
- there are many publications concerning nasal complications after
þ endonasal surgery, only a few publications describe the pathology
and anatomical variations detected during preoperative nasal
evaluations.6-9
-
Septum deviations are one of the most challenging pathologies
- encountered when reaching the sellar region during endonasal
surgical procedures. These deviations may lead to surgeon failure,
- especially among inexperienced surgeons, or the development of
serious nasal problems in the patient.10 In adults, septum deviation
-
can be present in up to 90% of the population.11 In our study,
septum deviation was the most common pathology (17%; n ¼ 17).
www.journals.elsevier.com/world-neurosurgery e825
 ORIGINAL ARTICLE
TOLGA GEDIZ AND ERDEM ÖZER GÜR NASAL PATHOLOGIES IN TRANSNASAL SURGERY

Table 2. Sinonasal Pathologies and Treatments

Patient Nasal Pathology SD Type* SD Degreey Surgical Approach Additional Surgery

1. Septum deviation S III Endonasal Perioperative septoplasty

2. Septum deviation C III Microscopic -
3. Septum deviation C I Microscopic -
4. Chronic sinusitis - - Microscopic -
5. Septum deviation C I Endonasal -
6. Lower concha hypertrophy - - Endonasal Lateralization of the inferior turbinate
7. Operated septum, perforated - - Microscopic -
8. Chronic sinusitis, giant middle concha bullosa - - Endonasal Concha bullosa opening and resection
of its inferior portion
9. Septum deviation C III Microscopic -
10. Septum deviation S II Microscopic -
11. Right maxillary sinus mucosel ethmoid sinusitis - - Microscopic -
12. Septum deviation C III Endonasal Perioperative septoplasty
13. Sphenoid sinusitis - - Endonasal -
14. Septum deviation C II Microscopic -
15. Septum deviation C III Microscopic -
16. Right maxillary sinus mucosal, ethmoid sinusitis - - Endonasal -
17. Septum deviation S III Microscopic -
18. Septum deviation C III Microscopic -
19. Inferior turbinate hypertrophy - - Microscopic -
20. Septum deviation, chronic sinusitis with polyp C I Endonasal Endoscopic sinus surgery
21. Septum deviation S III Microscopic -
22. Bilateral maxillary sinusitis - - Endonasal -
23. Septum deviation C II Microscopic -
24. Chronic Sinusitis with polyp - - Microscopic -
25. Frontal osteoma - - Microscopic -
26. Septum deviation C I Microscopic -
27. Chronic sinusitis with polyp - - Endonasal Endoscopic sinus surgery
28. Septum deviation, lower concha hypertrophy C III Endonasal Lateralization of the inferior turbinate,
perioperative septoplasty
29. Septum deviation S II Endonasal Perioperative septoplasty

SD, septum deviation.

*According to Guyuron’s classification for nasal septum deviation.
yAccording to the classification of Vidigal et al.2 for nasal septum deviation.

Although its use is decreasing, the microscopic approach con-
tinues to be frequently used by neurosurgeons. During the
microscopic approach, selection of the appropriate nostril and
working through the speculum can be advantageous in patients
with septum deviations, but severe deviations may also increase
the difficulty of the surgery. Nasoseptal complications, especially
septum perforation, have been reported to be more common with
the microscopic approach.12 On the other hand, lower rates of
nasoseptal complications are noted with endonasal surgery.
Several studies demonstrate that creating a suitable corridor for
endonasal surgery after septoplasty minimizes mucosal damage
and reduces the incidence of nasal problems, such as
postoperative adhesions.9,13 However, even mild septum
deviations may complicate the use of an endoscope such that
preoperative or perioperative septoplasty may be required.
Methods such as middle/inferior turbinate lateralization, partial

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 ORIGINAL ARTICLE
TOLGA GEDIZ AND ERDEM ÖZER GÜR NASAL PATHOLOGIES IN TRANSNASAL SURGERY

Figure 1. S-shaped, degree III deviation..

middle turbinate resection, and concha bullosa removal can be
used to optimize the nasal corridor.14-16 Although these methods
can make the nasal corridor suitable, they cannot eliminate
problems due to septum deviation. Most of these cases require
septoplasty. With perioperative septoplasty, both problems can be
resolved in a single surgical procedure.
In most clinics, paranasal sinus CT is performed to evaluate
the sphenoid sinus structure prior to surgery8,17; however,
particularly in clinics where only the endonasal approach is
performed by neurosurgeons, this examination often focuses
on a limited area such that the nasal cavity cannot be properly
evaluated and nasal pathologies can be missed. In our
hospital, the endonasal surgical approach is performed in both
the ENT and neurosurgery clinics such that preoperative
patient evaluation can be performed by both disciplines. The
patients are thoroughly examined endonasally before surgery,
and the examination findings are evaluated in conjunction with
the paranasal sinus CT. Depending on the nature of the
pathology of patients with endonasal problems, treatment is
performed before or in combination with sellar surgery.
Although a septum deviation will impede access to the sellar
pathology, the degree of deviation and the approach taken will
determine the difficulty of access. In our retrospective review,
since endonasal pituitary surgery was performed jointly by
neurosurgeons and ENT surgeons, septoplasty surgery was
performed perioperatively whenever necessary. Under our

Figure 2. C-shaped, degree III deviation.

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 ORIGINAL ARTICLE
TOLGA GEDIZ AND ERDEM ÖZER GÜR NASAL PATHOLOGIES IN TRANSNASAL SURGERY

Figure 3. Pituitary adenoma and nasal polyposis.

classification, we emphasize that septoplasty will be required
for a microscopic approach only in patients with an S-shaped,
grade II or III deviation. We also emphasize that in endonasal
surgical cases, especially under binostril study, septoplasty
should be performed in both severe C- and S-shaped
deviations.
The risk of meningitis increases after sellar surgery in patients
with acute sinusitis18; therefore, surgery is recommended after the
treatment of acute sinusitis.19,20 On the other hand, asymptomatic
but radiologically determined sinonasal infections are thought to
not increase postoperative morbidity.21 In our clinic, all patients
diagnosed with acute sinusitis were treated medically and then
transnasal surgery was performed. We did not encounter any
meningitis cases postoperatively.
Nasal pathologies other than septum deviation may also be
observed in patients who are about to undergo pituitary surgery.
According to Twigg et al., 62% of patients have a deviated nasal
septum, 32% patients have a concha bullosa of the middle turbi-
nate, and 22% have evidence of nasal disease in the form of polyps
or mucosal thickening on preoperative CT imaging.8 In our study,
34 nasal pathologies were detected in 29 (29.5%) of the 98 patients
who underwent pituitary macroadenoma surgery. The nasal
pathology rates from this study are similar to those in other
published studies.5,8
In cases of polyposis that fill the nasal passage or involve the
isolated sphenoid sinus, polyps that constitute a mechanical
obstacle should be removed to enable the surgeon to have
adequate vision and reach the sella floor, especially during
endonasal surgery. Endoscopic sinus surgery was performed in 2
patients with chronic sinusitis with polyps; the endonasal
approach was used for these patients, both to provide access to the
sellar region and as surgical treatment of simultaneous chronic
sinusitis with polyps. Pituitary surgery was performed without
endoscopic sinus surgery in one patient with chronic sinusitis with
polyps who underwent the microscopic approach. Although the
number of patients showing the coexistence of nasal polyps and
pituitary adenomas was not sufficient to make a formal evaluation,
it is certain that the polyps, which constitute a mechanical

Figure 4. Maxillary sinus mucosele, inferior turbinate hypertrophy, and pituitary adenoma.

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 ORIGINAL ARTICLE
TOLGA GEDIZ AND ERDEM ÖZER GÜR NASAL PATHOLOGIES IN TRANSNASAL SURGERY

obstacle, must be removed to obtain the necessary vision and
reach the base of the sella.
CONCLUSIONS
The presurgical detection of pathologies that may create me-
chanical barriers to reaching the sella floor may increase the
success of the planned pituitary surgery. Moreover, the detection
and treatment of infective nasal events are valuable in terms of
mitigating meningitis risk. The preoperative evaluation of patients
undergoing endonasal transsphenoidal surgery by an ENT surgeon
enables the detection and treatment of nasal pathologies that may
lead to serious perioperative complications. We believe that eval-
uating patients with septum deviations using our classification
will help determine the necessity of preoperative or perioperative
septum surgery, depending on the preferred pituitary surgical
method. However, further larger studies are needed to confirm
these results.
CRediT AUTHORSHIP CONTRIBUTION STATEMENT
Tolga Gediz: Conceptualization, Data curation, Methodology,
Writing e original draft. Erdem Özer Gür: Writing e review &
editing.
ACKNOWLEDGMENTS
The preparation for publication of this article was partly supported
by the Turkish Neurosurgical Society.

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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 7 March 2022; accepted 13 May 2022
Citation: World Neurosurg. (2022) 164:e824-e829.
https://doi.org/10.1016/j.wneu.2022.05.059
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2022 Elsevier Inc. All
rights reserved.

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