Nasal morbidity and complications after endoscopic transsphenoidal pituitary adenoma surgery

Abstract

Background:

Endoscopic transnasal transsphenoidal (ETT) surgery has become the standard approach for pituitary adenoma resection, yet postoperative nasal morbidity remains a concern. This study aims to evaluate rhinologic outcomes after ETT surgery, characterize the types and frequencies of postoperative nasal complications, and assess the effectiveness of treatment strategies. The primary research question addresses the incidence and reversibility of nasal morbidity following ETT surgery.

Methods:

A retrospective review was performed on 414 patients who underwent ETT surgery for pituitary adenomas at our institution between August 2015 and August 2025. Postoperative nasal complaints and complications were documented, including epistaxis, sinusitis, nasal adhesions, olfactory disturbances, and crusting. Clinical outcomes following targeted treatments were analyzed.

Results:

Seventeen patients (4.1%) experienced postoperative nasal complications. These included epistaxis (n = 2), isolated sphenoid sinusitis (n = 3), nasal adhesions (n = 4), olfactory disorders (n = 2), and nasal crusting (n = 6). All complications were managed conservatively or with minor interventions, and all affected patients experienced clinical improvement and symptom resolution during follow-up.

Conclusion:

Postoperative rhinologic complication rates following ETT surgery for pituitary adenomas are low and generally reversible with appropriate management. These findings support the safety of the ETT approach while emphasizing the importance of careful perioperative planning and postoperative nasal care.

INTRODUCTION

The introduction of the endoscopic transnasal transsphenoidal (ETT) approach has significantly changed the concept of surgery for pituitary gland tumors. The patient’s surgical exposure is improved by forming a wide corridor that also allows for the harvesting of nasal flaps for reconstruction and instrument accommodation.[8,15] The ETT approach aims to reduce morbidity, preserve nasal functions, and maintain a better quality of life (QoL) compared to traditional surgical concepts.[15]

After ETT surgery, patients may experience epistaxis and acute rhinosinusitis in the early postoperative phase. Late complications may include nasal crustations, septum perforation, and synechiae. While some series have not reported a decrease in overall smell function after ETT pituitary surgery, olfactory impairment should be considered, especially on the donor side of the nasoseptal flap.[4,15,16]

Although cerebrospinal fluid (CSF) leak is one of the most frequently reported complications in the literature, it is primarily addressed in terms of sellar reconstruction rather than nasal morbidity.[4,15,16] Therefore, the focus of the present study is on postoperative nasal complications, including epistaxis, crusting, adhesion, sinusitis, and olfactory changes, rather than CSF leaks. By combining institutional data with existing literature, we aim to provide a comprehensive overview of the rhinologic outcomes following ETT pituitary surgery.

MATERIALS AND METHODS

Study design

The Ethics Committee of the Faculty of Medicine, Zagazig University, Egypt, approved this study. We retrospectively reviewed patients who underwent ETT surgery for pituitary adenoma at the University Hospital between August 2015 and August 2025. Patients with pathologies other than pituitary adenoma were excluded. Of 468 eligible patients, 414 met the inclusion criteria and were included in the final analysis; 54 patients were excluded due to incomplete or missing follow-up data. All data were collected and extracted from the hospital database and operative registry in accordance with predefined inclusion and exclusion criteria.

The procedure starts with bilateral outer mobilization of the inferior and middle turbinate. Care was taken not to resect the middle or superior turbinate in every patient to preserve the nasal physiology. Unilateral partial removal of the middle turbinate was only done if there was severe turbinate hypertrophy interfering with surgery and narrowing the surgical corridor. Bilateral sphenoidectomy, raising a septal rescue flap, and removal of the anterior face of the sphenoid, together with posterior septectomy, is done. Wide exposure of both sphenoids after removal of all intersphenoid septae is done to expose the Sella, clivus, and both opticocarotid recesses.

During the procedure, the olfactory fibers were spared by keeping the superior turbinate and cranial septal mucosa intact. In some patients, an endoscopic septoplasty was performed by making an incision just in front of the deviated parts of the septum. This was done to make the surgery easier, broaden the surgical pathway, and improve the nasal airway after the procedure.

During surgery, the anterior wall of the sphenoid sinus was widely opened after exposing the sella. A cruciate-shaped durotomy was then performed, and the intradural adenoma was removed using standard techniques [Table 1]. After tumor resection, the sphenoid sinus was packed with Gelfoam^® (Pfizer, Inc.), and in some cases, Surgicel^® was applied within the sphenoid sinus and sellar cavity for hemostasis and support of reconstruction; it was not routinely left in the nasal cavity. Surgicel^® use may be associated with postoperative complications due to delayed resorption, foreign-body reaction, impaired mucociliary clearance, or obstruction of sphenoid sinus drainage, potentially predisposing patients to sphenoid sinusitis and olfactory dysfunction.

Table 1:

Surgical techniques applied in sellar and nasal reconstruction.

Nasal packing was not routinely used except in patients with CSF leaks or intraoperative mucosal oozing. In such cases, the nasal cavity was packed with Merocel^® (Medtronic Xomed, Inc.), which was removed 2–6 days postoperatively, depending on the reconstruction status. When a nasoseptal flap was employed, a septal stent was placed and left in situ for 2–3 weeks. To promote healing, patients were instructed to perform frequent nasal irrigation with isotonic saline for 1 month. Follow-up visits were scheduled every 2 weeks during the 1^st month and monthly thereafter for 6 months to remove crusts or debris. Ear, nose, and throat endoscopic examinations were performed either routinely during follow-up or whenever patients reported symptoms or complications.

We gathered data on patients and their tumors, including age, gender, surgery date, and tumor size. We also noted if the tumor was hormone-secreting or not. Before the surgery, we categorized the rhinologic findings as either having a documented septal deviation or pre-existing sinusitis. After the surgery, we divided the rhinologic outcomes into early complications, such as epistaxis or acute rhinosinusitis, and late complications, such as prolonged crusting, longstanding synechiae, or septal perforation. We defined early complications as those occurring within 1 month of the surgery and late ones as those occurring after.

Acute rhinosinusitis is a condition characterized by symptoms such as pain, pressure, and discharge, as well as examination findings such as purulent secretion and edematous mucosa. The sites of the synechiae are classified into four types: (1) septum and inferior turbinate, (2) septum and middle turbinate, (3) superior turbinate and sphenoid ostia, and (4) a complex one involving the septum, inferior turbinate, and middle turbinate. Crusting is defined as symptomatic (obstruction and discharge), detected by endoscopy, requiring endoscopic removal, and present for more than 2 months.

The smell pre- and post-surgery was tested using the Sniffing Sticks Smell test^®, which scores on a scale of 0–12 points. According to the standards set by Hummel et al., scores of 10 or higher indicate a normal sense of smell, 7–9 points indicate a reduced sense of smell (hyposmia), and scores lower than 6 indicate a complete loss of sense of smell (anosmia).[11]

Postoperatively, the patients underwent a rhinologic follow-up, including an endoscopic examination and a bilateral smell test within 8–12 weeks after surgery. In the case of any documented complications, follow-up visits were extended until full improvement.

Statistical analysis

Descriptive statistics were used to summarize patient demographics, clinical characteristics, tumor features, surgical techniques, and postoperative outcomes. Continuous variables, including age and tumor size, were expressed as mean ± standard deviation with range. Categorical variables, such as sex, tumor type, recurrence, prior sinus surgery, history of sinusitis, nasal septal deviation, surgical techniques applied (nasal septal flap/splints, fascia/fat graft, Surgicel^® use, middle turbinate removal, autograft septal bone reconstruction), and postoperative nasal complications (epistaxis, nasal adhesions, crustation, sphenoid sinusitis, olfactory disorder) were reported as frequencies and percentages.

Associations between categorical variables and postoperative nasal complications were initially evaluated using univariate analysis with the Chi-square test or Fisher’s exact test, while comparisons of continuous variables were performed using the independent t-test. Variables with a P < 0.1 in univariate analysis were further included in a multivariate logistic regression model to identify independent predictors of nasal complications. Odds ratios (OR) with 95% confidence intervals (CI) were reported, and a P < 0.05 was considered statistically significant. All statistical analyses were performed using IBM Statistical Package for Social Sciences Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA).

RESULTS

In this study, there were 273 female patients and 141 males. The tumors were classified as 263 non-secreting adenomas and 151 functioning adenomas, with main tumor sizes ranging from 0.7 to 3.5 cm. Out of the total patients, 40 (9.7%) patients were recurrent. 31 patients had a history of functional endoscopic sinus surgery, and 61 had a history of sinusitis before. In addition, 20 patients had a septal deviation that was detected in their pre-operative computed tomography (CT) scans [Table 2].

Table 2:

Clinical and demographic data.

Epistaxis

During our research, we discovered that two patients experienced postoperative epistaxis. We found a statistically significant difference (P = 0.003) between these patients and the presence of nasal septal deviation. One patient had a history of nasal septal deviation, which accounted for 5% of the cohort, while the other patient had only a 0.3% likelihood of having the condition based on resting data. And were found slightly statistically significant as (P = 0.049) regarding patients’ sex, were encountered in two male patients, one of them was hypertensive in the history, and all of them had significant bleeding and required no surgical action.

Nasal adhesions

In our study, four patients experienced postoperative nasal adhesions, which was significant with a P = 0.000. Specifically, 75% of the patients who encountered this issue had a septal splint and septal flap during the surgical technique. However, all patients had minimal symptoms and did not require any further intervention except outpatient endoscopic toilet and balloon dilatation [Figure 1].

Figure 1:

Endoscopic view of the left nasal cavity, (A and B) showing adhesions between the septum and posterior end of the middle turbinate with a patent airway.

Crustations

Six patients exhibited nasal crusts after their surgery. All of them had a grade II or III intraoperative CSF leak and were reconstructed using a nasoseptal flap. Our results indicate a statistically significant difference (P = 0.000). All of them were managed by frequent endoscopic cleaning and nasal irrigation [Figure 2].

Figure 2:

Endoscopic view of the right nasal cavity showing nasal crustation over the septum.

Sphenoidal sinusitis

Three patients developed saprophytic/superficial fungal infections after surgery and were treated with nasal irrigation and local corticosteroids. Our results showed statistical significance (P = 0.011) about a history of sinusitis, which was present in 2 out of the 3 patients (66.7%). Another statistically significant finding (P = 0.037) was the use of fat graft and fascia lata during the surgical technique, which was present in 2 out of 3 patients (66.7%) compared to other patients. The use of Surgicel^®, Ethicon, Inc., during the surgical technique was strongly statistically significant (P = 0.000) and was present in all 3 patients (100%) [Figure 3].

Figure 3:

(A-B) Endoscopic view of the sphenoid sinus of two different patients, both with saprophytic infection.

Olfactory disorder

Two female patients developed bilateral olfactory disorder after surgery, with a slightly significant correlation (P = 0.049) regarding their sex. The results showed a statistically significant correlation (P = 0.022) between previous sinus surgery and the occurrence of the disorder, which was observed in 2 (3.2%) patients. Furthermore, a strong statistical correlation (P = 0.004) was observed between the use of Surgicel^® during surgery and the development of the disorder, which was observed in all 2 patients who used it. Despite treatment with local and systemic corticosteroids and neurotonics for 3 months, there was unfortunately no improvement detected, and endoscopy showed no nasal adhesions.

The analysis of postoperative care revealed that nasal packing was significantly associated with a higher risk of nasal complications (12/17; Chi-square = 7.51, P = 0.006), whereas regular nasal irrigation was strongly protective, with only 2/17 patients affected (Chi-square = 89.26, P < 0.001). These results highlight the importance of routine postoperative nasal washing and cautious use of nasal packing to reduce nasal morbidity [Table 3].

Table 3:

Impact of postoperative care on nasal complications.

The overall incidence of postoperative nasal complications was 4.1% (17/414). Univariate analysis indicated that epistaxis was significantly associated with male sex and septal deviation, nasal adhesions with septal flap/splints, crustation with intraoperative CSF leak and nasoseptal flap, sphenoid sinusitis with prior sinusitis, fat/fascia graft, and Surgicel^® use, and olfactory disorder with female sex, prior sinus surgery, and Surgicel^® usage. Multivariate logistic regression demonstrated that postoperative nasal packing independently increased the risk of nasal complications (OR = 7.0, 95% CI: 2.1–23.0, P = 0.002), whereas regular postoperative nasal washing had a strong protective effect (OR = 0.1, 95% CI: 0.02–0.5, P = 0.003). Other factors, including sex, septal deviation, prior sinus surgery, history of sinusitis, and specific surgical techniques, showed trends toward association but did not reach statistical significance. These findings highlight the critical role of postoperative care in minimizing nasal morbidity following ETT pituitary surgery [Table 4].

Table 4:

Multivariate logistic regression analysis of risk factors for nasal complications following ETT pituitary surgery.

DISCUSSION

The incidence of postoperative complications in endoscopic pituitary surgery is low. Pre- and postoperative smell function is comparable, in case no nasoseptal flap is harvested. Regular postoperative follow-up examination is an important factor in optimal postoperative nasal care [Table 5].

Table 5:

Postoperative nasal complications and risk factors compared with literature.

The nasal endoscope offers several advantages in treating sphenoid sinus diseases during otolaryngology surgery. These benefits include precise localization, the ability to observe the region and extent of the disease from multiple angles, and the ability to establish a clear drainage pathway through regular review and treatment. In addition, the nasal endoscope helps protect nasal physiological functions, minimizes injury, and considers the concept of functional surgery in postoperative management.[14]

With a particular focus on nasal complications, Jain et al. found a higher rate of epistaxis and septal deformities in the microscopic group.[12] In addition, higher rates of acute sinusitis and synechiae were reported in the literature.[13] Regarding smell function, some authors reported a favorable outcome for the endoscopic approach.[9,10] Consistent with previous studies, the analysis of our hospital cohort revealed low rates of early and late complications.

In the literature, the rates of epistaxis after ETT surgery varied between 0% and 4%.[9] The studies that were conducted did not offer any information on the cause of postoperative epistaxis or how to treat it. In our group, two instances of epistaxis occurred, but they were both mild to moderate and treated with hemostatic packing.

Batra et al.[1] reported 200 cases of endonasal resection of pituitary adenomas, and they discovered that 7.5% of patients developed nasosinusitis after surgery, with an average duration of 2.9 years. In our series, all postoperative sinusitis was managed with good local care and proper antibiotics.

Postoperative sphenoid sinusitis can be caused by several factors. In addition, the nasal mucosa, particularly the mucosa of the sphenoid sinus, can be severely damaged during the operation, leading to obstruction of the sphenoid sinus drainage due to damage to the mucosa-mucus-cilium system.[2] Hence, surgeons must use the correct surgical method. This involves examining CT and endoscopy images and focusing on three key points. First, it is important to retain the middle turbinate. Second, when the patient has a deviated nasal septum, the lateral nasal wall should be used for a direct surgical approach.[6] Next, surgeons need to focus on preserving the nasal mucosa during the procedure. In addition, careful and gentle postoperative nasal packing is necessary, including fixing the middle turbinate in its normal position and removing the packing as soon as possible.

Our research suggests that closely monitoring and reviewing the nasal cavity through nasal endoscopy and the local application of medication are the most effective ways to prevent and treat sphenoid sinusitis following surgery.

The olfactory-smell disorder is another complication after endonasal resection of PNs.[3] extensive coagulation of the hemorrhagic mucosa, and poor protection of the mucosa. In particular, the injury of the turbinal and septal mucosa, which contains olfactory receptors, can contribute to these negative disorders.

After surgery, to decrease nasal inflammation and avoid smell disorder, the examination should be emphasized, as a regular review of the nasal cavity. The objective of the follow-up is to prevent complications and to do the cleaning of blood-dried clots, granulation tissues, and vesicles, which can improve nasal-paranasal sinus aeration and drainage. Moreover, for the recovery of olfactory function, it is necessary to perform comprehensive management such as endoscopic examinations, systemic and local corticosteroids, nerve nutrition, and nasal irrigation.

Postoperative adhesion may be attributed to rhinosinusitis, edema, drifting of the middle nasal concha, the granulation tissue, dysfunction of the epithelium, and lack of proper follow-up.[5] During our study, we observed that four patients developed postoperative nasal adhesions. Among those affected, 75% patients had undergone a surgical technique involving a septal splint and septal flap. However, the adhesions were minimal and did not require any further surgical intervention.

The low complication rates in our cohort are consistent with published series [Table 5]. For example, Batra et al.[1] (2005) reported a 7.5% rate of postoperative sinusitis in 200 cases, while Haruna et al.[9] (2007) observed epistaxis in 2–4% of patients following ETT pituitary surgery. Chaaban et al. [3] (2015) and Schreiber et al. [15] (2019) reported minimal long-term olfactory deficits, with rates comparable to our findings of 0.5%. Gstrein et al. reported that the rates of early and late postoperative rhinologic complications after ETT surgery for pituitary lesions appear to be low.[7] Weiland et al. found that the concept of minimally invasive endoscopic tumor resections on the pituitary gland with preservation of nasal turbinates shows low morbidity for the patient.[17]

Our data suggest that careful intraoperative techniques – such as preserving the middle and superior turbinates, sparing olfactory mucosa, and limiting unnecessary nasal trauma – play a critical role in reducing nasal morbidity. In addition, the use of nasoseptal flaps, septal splints, fat/fascia grafts, and hemostatic agents, while sometimes associated with temporary crustation or adhesions, did not result in long-term complications in most patients. A history of sinusitis or prior sinus surgery was associated with slightly higher rates of sinus complications, reflecting the importance of pre-operative evaluation [Table 5]. Overall, these results support previous literature demonstrating that ETT surgery is safe from a rhinologic standpoint, with minimal, mostly reversible complications even in large series of patients.

Our findings suggest that the reduction of unnecessary damage and gentle, precise operation to protect the nasal cavity, nasal normal mucosa, and regenerating tissues can prevent nasal adhesion and lead to good cavity epithelization. Our analysis demonstrates that postoperative care significantly influences nasal morbidity following endoscopic transsphenoidal pituitary surgery. Xu et al. reported that nasal irrigation helps reduce the incidence of complications such as epistaxis and nasal adhesions in the early postoperative period. It can also promote the elimination or reduction of olfactory disturbances.[18]

Nasal packing was associated with a higher incidence of complications, while routine nasal washing strongly correlated with fewer postoperative nasal issues. These findings highlight the protective role of nasal irrigation in minimizing crusting, adhesions, and other nasal complications, aligning with previous studies emphasizing careful nasal care to preserve mucosal function and promote healing. Although nasal packing may be necessary in certain situations, it should be used judiciously to avoid increasing the risk of postoperative morbidity. Overall, meticulous postoperative nasal management is essential to optimize patient outcomes and maintain long-term nasal function [Table 4].

Limitations, this single-center, retrospective study did not include formal patient-reported outcome measures (e.g., sinonasal QoL questionnaires) and had a low incidence of complications, which limits statistical power. Follow-up was limited to 12 months, potentially missing late-onset complications.

Availability of data and materials

All data generated or analyzed during this study are included in this published article in the results section.

CONCLUSION

Postoperative rhinologic complications after ETT surgery for pituitary adenoma are generally low. However, it’s important to conduct a comprehensive pre-operative evaluation, especially for patients at risk of CSF leak and who need a nasoseptal flap, to optimize long-term nasal outcomes. In addition, postoperative care plays a critical role: routine nasal washing is strongly associated with fewer nasal complications, while indiscriminate nasal packing may increase the risk of morbidity. These findings underscore the importance of tailored surgical planning and diligent postoperative management to preserve nasal function and minimize complications.

Ethical approval:

The research/study approved by the Institutional Review Board at Zagazig University, Faculty of Medicine, number 545, dated August 11, 2024.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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