DISCUSSION
Our study revealed that the transseptal approach had better
patient-reported outcomes and objective endoscopic scores with intact
olfactory function. Meanwhile, the neurosurgical outcomes and rate of
complications were comparable. That is, endoscopic transseptal TSA
facilitates nasal recovery without compromising neurosurgical outcomes.
In recent years, neurosurgeons and otolaryngologists have been making a
joint effort to reduce nasal morbidities.13-17 There
is increasing evidence indicating that endoscopic transnasal TSA has
better neurosurgical outcomes and fewer complications than microscopic
transsetpal TSA,18-20 while the sinonasal outcomes
have been inconsistent.7, 21, 22 Interestingly, Hong
et al. found better sinonasal quality of life in the early postoperative
period in the microscopic transseptal group than in the endoscopic
transnasal group.7 They proposed that their finding
was because they avoided injury to the nasal mucosa in the microscopic
transseptal approach. That is, the transseptal approach has a great
potential with excellent nasal outcomes when manipulating nasal tissue
carefully.
Therefore, the endoscopic endonasal transseptal approach can be deemed
as a favorable technique with the advantages of both approaches:
comparable neurosurgical outcomes from the endoscopic transnasal
approach and minimal nasal morbidities from the microscopic transseptal
approach. Previous studies reported solely on either neurosurgical or
rhinological outcomes. Favier et al. reported similar gross total
resection, endocrine outcomes and rates of neurosurgical complication in
endoscopic transseptal approach comparing to results of endoscopic
transnasal approach from other experienced teams. 4, 5Hong et al. reported fewer subjective nasal symptoms in the early
postoperative period after the endoscopic transseptal
approach.6 This study demonstrated lower SNOT-22
scores, lower postoperative Lund-Kennedy scores and intact olfactory
function in the transseptal group. Meanwhile the neurosurgical outcome
and rates of complications were not inferior. That is, the endoscopic
transseptal approach enhances nasal recovery without compromising
resection, making it a worthy tradeoff for better rhinological outcomes.
We observed that olfactory function was well preserved in both groups.
The possible explanation is that olfactory neural fibers was not
disrupted in either approaches.23 In the transseptal
approach, the incisions are made anteriorly and the olfactory nerves can
be retained within the elevated mucosal flaps. The binostril method also
allows for less tension in the mucosal flap, preventing an unbalanced
force from disrupting the olfactory neuroepithelium, as in microscopic
TSA.24 For the transnasal approach, the main route
includes the posterior septum and spared the main olfactory
neuroepithelium from permanent dysfunction.25
Some may concern that managing unexpected high-flow intraoperative CSF
leakage could be problematic for the endoscopic transseptal TSA. On the
contrary, a nasoseptal flap can be harvested by dividing the septal
mucosal flap superiorly and inferiorly. For patients with a high risk of
CSF leakage, the septal incision can be made anteriorly to develop a
larger nasoseptal flap.
Even though the endoscopic transseptal approach seems attractive,
surgeons should remember that every procedure has its limitations.
Dissection of the septal mucosal flap could be difficult in patients
with previous nasal surgery including TSA, septoplasty and rhinoplasty.
In addition, tumors with lateral extension to the cavernous sinus cannot
be removed thoroughly. Finally, although septal infection presented only
in one patient in our series, severe septal infection may result in
perforation or nasal deformity. We should carefully examined patients
with unusual postoperative nasal pain.
There were several limitations in this study. First, the study was
retrospective in nature. Although we have controlled as many confounding
factors as possible, the results still require validation by a
prospective randomised controlled studies. Second, we included only
pituitary adenoma and whether the conclusions can be generalised to
other sellar pathologies remains unexplored. Finally, we only analysed
data until 1 year after surgery. Long-term complications, especially for
septal complications, require a longer follow-up.