A case series and review of the mononostril endoscopic transnasal transsphenoidal approach: Safe and effective in a low resource setting

• Published in: Clinical neurology and neurosurgery 2021-03, Vol.202, p.106499-106499, Article 106499
• Main Authors: Peeters, Sophie, Levinson, Simon, Wahjoepramono, Eka J., July, Julius
• Format: Article
• Language: English
• Subjects: Adenoma; Adenoma - surgery; Adolescent; Adult; Aged; Aged, 80 and over; Binostril; Cerebrospinal fluid; Clinical outcomes; Diabetes insipidus; Endoscopic surgery; Endoscopy; Epistaxis - epidemiology; Female; Growth hormones; Hospitals; Humans; Length of Stay; Literature reviews; Male; Middle Aged; Mononostril; Natural Orifice Endoscopic Surgery - education; Natural Orifice Endoscopic Surgery - methods; Neuroendoscopy - education; Neuroendoscopy - methods; Neurological disorders; Neurology; Operative Time; Pain, Postoperative; Patients; Pituitary; Pituitary adenoma; Pituitary Neoplasms - surgery; Postoperative Hemorrhage - epidemiology; Sinuses; Sphenoid Bone - surgery; Sphenoid Sinus; Surgery; Transsphenoidal transnasal surgery; Tumors; Visual field; Young Adult
• ISSN: 0303-8467; 1872-6968
• DOI: 10.1016/j.clineuro.2021.106499

•The mononostril TNTS surgery may reduce operative time and patient morbidity.•The mononostril approach can be safely performed without an ENT assist.•In low resource settings, it may conserve valuable OR and physician time.•Rates of complications and recurrence were comparable to binostril TNTS surgery. A transnasal transsphenoidal (TNTS) approach can be performed through a binostril or mononostril technique. The binostril technique is generally preferred, however the mononostril may be an underutilized approach with significant benefits. All (n = 521) pituitary adenoma transsphenoidal surgeries performed from March 2008 until July 2017 at a university hospital in Indonesia were isolated. The majority (n = 512) were performed through a mononostril approach with no nasal speculum by a single experienced neurosurgeon. A PubMed literature review researching the differences in indications, techniques, and outcomes for both approaches supplements the case series. The mononostril surgical technique is described in detail. The average mononostril operating time was 105 min. The most prevalent surgical complications were CSF leak (4.1 %), diabetes insipidus (3.7 %) and cacosmia (2.1 %). Visual field deficits noted in 85 %, 89 % improved. Length of stay was less than 2 days for 90 %, with 13 ICU admissions (average one day). Recurrence rate was 8.2 % at follow up (1–10 years). Based on a literature review, binostril TNTS surgeries have longer operative time and a higher risk of epistaxis. According to our experience, post-operative patient comfort and satisfaction are higher with the monostril approach. Furthermore, this technique is easier to teach, ENT assistance unnecessary, and thus especially advantageous in low resource settings. Our CSF leak and tumor recurrence rates were lower than reported binostril rates in the literature. The mononostril technique is both safe and effective and should be strongly considered for an appropriately pre-selected subset of pituitary adenomas.