Otolaryngology Considerations of Pituitary Surgery: What an Endocrinologist Should Know.

Endoscopic endonasal skull base surgery is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.

Posisep Versus PureRegen Gel for Post ESS Nasal Packing - A Randomized Blinded Prospective Study.

OBJECTIVE: Endoscopic sinus surgery (ESS) is the procedure of choice for chronic rhinosinusitis (CRS). Adhesions are the most common postoperative complications, causing recurrent disease and revision surgery. Postoperative care is thus essential for the healing of the operated cavity. A wide variety of packing materials are used to prevent bleeding and adhesions postoperatively. Two main absorbable packing materials are used: Foam-based packs (e.g., Posisep and Nasopore) and gel-based packs (PureRegen Gel - PRG). The current study is a randomized, blinded, prospective analysis of cavity healing using Posisep and PRG in ESS, aiming to compare the pros and cons of the two. METHODS: Patients with bilateral symmetric CRS were recruited for the study. At the end of surgery, one side was randomly packed with Posisep, whereas the other was packed with PRG. The postoperative cavity cleaning was video recorded and a blinded physician evaluated the mucosal healing. RESULTS: The side packed with Posisep had significantly less middle turbinate (MT) lateralization and adhesions yet dissolved significantly slower than the PRG, causing more mucosal edema. Severe MT scarring requiring recurrent medialization and adhesiolysis was exclusively observed in the PRG group. All differences were observed in the early postoperative period (up to 12 weeks after surgery). By that time, only the MT position was significantly different between groups, despite recurrent adhesiolysis and medialization. CONCLUSION: The authors recommend using Posisep for MT support only when it is unstable or lateralized. Packing the surgical cavity in other cases with PRG is more beneficial. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:1834-1838, 2023.

The diagnostic importance of periostin as a biomarker in chronic rhinosinusitis with nasal polyp.

PURPOSE: The current studies in the literature report that periostin contributes to the formation of nasal polyps and may be a molecular biomarker for chronic rhinosinusitis with nasal polyps (CRSwNP). This study aims to investigate the effect of periostin in determining polyp burden in CRSwNP patients and evaluate its impact on postoperative surgical results and its functionality as a biomarker. METHODS: The study included 26 patients who underwent endoscopic sinus surgery due to CRSwNP and 30 patients who were scheduled to undergo septoplasty due to isolated nasal septum deviation. We performed preoperative Lund-Mackay scoring and preoperative and postoperative SNOT-22 and Modified Lund-Kennedy scoring for the patients. Tissue and serum samples were collected from all patients in surgery and another serum sample was taken from CRSwNP patients at postoperative month 6. RESULTS: Tissue eosinophil (p < 0.001), preoperative serum (p < 0.001), and tissue (p = 0.002) periostin were significantly higher in the CRSwNP group. We observed a statistically significant positive correlation between tissue eosinophil values and tissue periostin values in CRSwNP patients (p = 0.004). We found a statistically significant positive correlation between the tissue periostin values and postoperative SNOT-22 scores of the CRSwNP group patients (p = 0.005). CONCLUSION: According to the results of our study, we think that periostin can be used as a biomarker in the prediction, determination of disease severity, and prognosis of CRSwNP. Comprehensive cohort studies with larger patient series are needed to provide more information on the role and effects of periostin in cases of CRSwNP undergoing surgical treatment.

Endoscopic modified transseptal bi-nostril approach for pituitary tumors. Efficacy of complex preservation of every turbinate and olfaction: A STROBE analysis.

AIMS: Endoscopic modified transseptal bi-nostril approach minimizes turbinate and olfactory mucosal invasion and ensures preservation of the turbinates and bilateral olfaction. The main objective of this study was to investigate the pre- and postoperative variations in olfactory function in patients using this approach, and the secondary objective was to investigate the complications associated with the surgical procedure. MATERIAL AND METHODS: This study is a single-center prospective cohort study using STROBE analysis. To completely protect the bilateral turbinates and olfactory epithelium, this procedure provided access to the sphenoid sinus by a transseptal approach via the left nasal cavity and by the olfactory cleft approach via the right nasal cavity without any turbinate resection. A T&T olfactometer was used to assess the mean recognition threshold of the left, right, and bilateral nasal passages before and after surgery, and complications associated with the surgical approach were investigated. OBJECTIVES: We included 27 patients who underwent endoscopic modified transseptal pituitary surgery with an olfactory and turbinate preservation approach at our hospital between April 2018 and December 2019. RESULTS: The mean postoperative recognition threshold of the right, left, and bilateral nasal cavities did not worsen (P<0.001 for all) relative to the preoperative values, and there was no difference in values between the right and left nasal cavities (P=0.85). The nasal turbinates were preserved in all patients during the study period, and no recurrence was observed. CONCLUSION: Our modified EETSA could be implemented as an approach for turbinate and olfaction preservation.

Evaluation of olfactory function in patients undergoing endoscopic skull base surgery with nasoseptal flap / Avaliação da função olfatória nos pacientes submetidos à cirurgia endoscópica da base do crânio com realização de retalho nasosseptal

Abstract Introduction Endoscopic transnasal access to the skull base, both for treatment and reconstruction, can cause olfactory morbidity. Knowing the main consequences of this intervention is essential to have objective criteria for decision-making regarding the appropriate surgical technique. Objectives The aim of this study is to determine the impact on olfactory function of the endonasal endoscopic access to the skull base with the creation of the nasoseptal flap. Methods A prospective research was carried out in which 22 patients who underwent endoscopic transnasal surgery at the skull base, with the creation of a nasoseptal flap. The Connecticut Chemosensory Clinical Research Center test was applied before and at the 1st, 3rd and 6th postoperative months. Results The results showed that only in the first month of follow-up the mean patient classification was statistically worse than at the other evaluation moments (p < 0.05), but there was no mean difference in the Connecticut score classification between the other moments (p > 0.05); that is, patients showed worsening in the 1st month and returned to the preoperative mean after the 3rd month of follow-up. Conclusion The present study showed that the postoperative decrease in olfaction is transient, since the patient's sense of smell returns to pre-surgical values in the 3rd postoperative month.

Resumo Introdução O acesso transnasal endoscópico à base do crânio, tanto no tratamento quanto na reconstrução, pode ocasionar morbidade olfatória. Conhecer as principais consequências dessa intervenção é fundamental para se dispor de elementos objetivos para a decisão da técnica cirúrgica adequada. Objetivo Determinar o impacto na função olfatória do acesso endoscópico endonasal à base do crânio com confecção do retalho nasosseptal. Método Foi feita pesquisa prospectiva na qual foram incluídos 22 pacientes submetidos à cirurgia endoscópica transnasal à base do crânio com confecção de retalho nasosseptal. Foi aplicado o teste Connecticut chemosensory clinical research center antes e após o 1°, 3° e 6° meses da cirurgia. Resultados Os resultados evidenciaram que apenas no 1° mês de seguimento a classificação média dos pacientes foi estatisticamente pior do que nos demais momentos de avaliação (p < 0,05), mas entre os demais momentos não houve diferença média na classificação do escore de Connecticut (p >0,05), ou seja, os pacientes pioraram no 1° mês e voltaram à média pré-operatória a partir do 3° mês de seguimento. Conclusão No presente estudo, demonstramos que a diminuição do olfato pós-operatória é transitória, já que, no 3° mês depois da cirurgia, o olfato do paciente retorna aos valores pré-cirúrgicos.

Evaluation of olfactory function in patients undergoing endoscopic skull base surgery with nasoseptal flap.

INTRODUCTION: Endoscopic transnasal access to the skull base, both for treatment and reconstruction, can cause olfactory morbidity. Knowing the main consequences of this intervention is essential to have objective criteria for decision-making regarding the appropriate surgical technique. OBJECTIVES: The aim of this study is to determine the impact on olfactory function of the endonasal endoscopic access to the skull base with the creation of the nasoseptal flap. METHODS: A prospective research was carried out in which 22 patients who underwent endoscopic transnasal surgery at the skull base, with the creation of a nasoseptal flap. The Connecticut Chemosensory Clinical Research Center test was applied before and at the 1st, 3rd and 6th postoperative months. RESULTS: The results showed that only in the first month of follow-up the mean patient classification was statistically worse than at the other evaluation moments (p<0.05), but there was no mean difference in the Connecticut score classification between the other moments (p>0.05); that is, patients showed worsening in the 1st month and returned to the preoperative mean after the 3rd month of follow-up. CONCLUSION: The present study showed that the postoperative decrease in olfaction is transient, since the patient's sense of smell returns to pre-surgical values in the 3rd postoperative month.

A Randomized Study on the Efficacy of Music Therapy on Pain and Anxiety in Nasal Septal Surgery

Abstract Introduction Nasal septal surgery is one of themost common surgeries performed by otolaryngology surgeons; however, anxiety before surgery and postoperative pain remain a significant cause of morbidity. The search for a complimentary modality to reduce the symptoms and side effects has gained momentum in recent years. Objective Music therapy is an exciting and inexpensive modality in this regard, but scientific evidence in terms of randomized clinical trials is still lacking for common otolaryngology surgeries. Hence, we performed the present study. Method The sample of our study was composed of 59 patients, 30 of which were submitted to conventional medicine, while the remaining 29 were submitted to both conventional medicine and music therapy with music of their own choice, with 2 sessions per day, each lasting 30minutes. This was performed using the generalized anxiety disorder-7 scale and the pain visual analogue scale until postoperative day 2, when the patients were discharged from the hospital. Result On comparing the anxiety and pain scores between the two groups, the group who underwent music therapy showed a statistically significant reduction in anxiety both preoperatively (p<0.0001) and postoperatively (p<0.0001), as well as reduced postoperative pain starting from day 0 (p<0.001), which continued until postoperative day 2 (p<0.001). Conclusion Music therapy is an effective adjunct in the control of anxiety and postoperative pain following nasal septal surgery.

A Randomized Study on the Efficacy of Music Therapy on Pain and Anxiety in Nasal Septal Surgery.

Introduction Nasal septal surgery is one of the most common surgeries performed by otolaryngology surgeons; however, anxiety before surgery and postoperative pain remain a significant cause of morbidity. The search for a complimentary modality to reduce the symptoms and side effects has gained momentum in recent years. Objective Music therapy is an exciting and inexpensive modality in this regard, but scientific evidence in terms of randomized clinical trials is still lacking for common otolaryngology surgeries. Hence, we performed the present study. Method The sample of our study was composed of 59 patients, 30 of which were submitted to conventional medicine, while the remaining 29 were submitted to both conventional medicine and music therapy with music of their own choice, with 2 sessions per day, each lasting 30 minutes. This was performed using the generalized anxiety disorder-7 scale and the pain visual analogue scale until postoperative day 2, when the patients were discharged from the hospital. Result On comparing the anxiety and pain scores between the two groups, the group who underwent music therapy showed a statistically significant reduction in anxiety both preoperatively ( p < 0.0001) and postoperatively ( p < 0.0001), as well as reduced postoperative pain starting from day 0 ( p < 0.001), which continued until postoperative day 2 ( p < 0.001). Conclusion Music therapy is an effective adjunct in the control of anxiety and postoperative pain following nasal septal surgery.

Comparing surgical experience with performance on a sinus surgery simulator.

BACKGROUND: This study evaluates whether surgical experience influences technical competence using the Flinders sinus surgery simulator, a virtual environment designed to teach nasal endoscopic surgical skills. METHODS: Ten experienced sinus surgeons (five consultants and five registrars) and 14 novices (seven resident medical officers and seven interns/medical students) completed three simulation tasks using haptic controllers. Task 1 required navigation of the sinuses and identification of six anatomical landmarks, Task 2 required removal of unhealthy tissue while preserving healthy tissue and Task 3 entailed backbiting within pre-set lines on the uncinate process and microdebriding tissue between the cuts. RESULTS: Novices were compared with experts on a range of measures, using Mann-Whitney U -tests. Novices took longer on all tasks (Task 1: 278%, P < 0.005; Task 2: 112%, P < 0.005; Task 3: 72%, P < 0.005). In Task 1, novices' instruments travelled further than experts' (379%, P < 0.005), and provided greater maximum force (12%, P < 0.05). In Tasks 2 and 3 novices performed more cutting movements to remove the tissue (Task 2: 1500%, P < 0.005; Task 3: 72%, P < 0.005). Experts also completed more of Task 3 (66%, P < 0.05). CONCLUSIONS: The study demonstrated the Flinders sinus simulator's construct validity, differentiating between experts and novices with respect to procedure time, instrument distance travelled and number of cutting motions to complete the task.