ORIGINAL ARTICLE
Rate of rhinosinusitis and sinus surgery following a minimally destructive
approach to endoscopic transsphenoidal hypophysectomy
Ryan A. Rimmer, MD1 , Swar Vimawala, BS1 , Chandala Chitguppi, MD1 , Erin K. Reilly, MD1 ,
Alexander E. Graf, BA2 , Judd H. Fastenberg, MD1 , James J. Evans, MD3 , Marc R. Rosen, MD1 ,
Mindy R. Rabinowitz, MD1 and Gurston G. Nyquist, MD1
Background: There remains considerable variation in the
extent of sinonasal preservation during the approach for
endoscopic transsphenoidal hypophysectomy (TSH). We
advocate for a minimally destructive approach utilizing
turbinate lateralization, small posterior septectomy, no eth-
moidectomy, and preservation of nasoseptal flap (NSF)
pedicles bilaterally. Due to these factors, this approach may
affect the rates of postoperative rhinosinusitis. The objec-
tive of this study is to define the rates of postoperative rhi-
nosinusitis in patients undergoing this approach.
Methods: Single institution, retrospective chart review of
patients undergoing TSH from 2005 to 2018.
Results: A total of 415 patients were identified and 14% de-
veloped an episode of postoperative rhinosinusitis within
3 months. These patients were significantly more likely
to have had a history of recurrent acute or chronic rhi-
nosinusitis. Most cases were sphenoethmoidal sinusitis
managed with 1 to 2 courses of antibiotics. Of patients
with postoperative rhinosinusitis, most did not undergo
NSF. Average follow-up was 38 months. Six patients (1.4%)
underwent post-TSH functional endoscopic sinus surgery
(FESS). Average time from TSH to FESS was 26.3 months.
Two of these patients had a history of prior chronic
1 Department of Otolaryngology–Head and Neck Surgery, Thomas
Jefferson University Hospital, Philadelphia, PA; 2 Sidney Kimmel
Medical College, Thomas Jefferson University, Philadelphia, PA;
3 Department of Neurological Surgery, Thomas Jefferson University
Hospital, Philadelphia, PA
Correspondence to: Ryan A. Rimmer, MD, Department of
Otolaryngology–Head and Neck Surgery, Thomas Jefferson University
Hospital, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107; e-mail:
Ryan.rimmer@jefferson.edu
Potential conflict of interest: None provided.
Presented at RhinoWorld on June 5-9, 2019, in Chicago, IL.
Received: 13 May 2019; Revised: 14 October 2019; Accepted:
15 October 2019
DOI: 10.1002/alr.22482
View this article online at wileyonlinelibrary.com.
rhinosinusitis without polyposis. Two patients underwent
revision TSH for recurrent tumor as the primary indication
for surgery at time of FESS. Twenty-two–item Sino-Nasal
Outcome Test (SNOT-22) scores generally increased im-
mediately postoperatively, but frequently decreased below
preoperative level by the time of last follow-up, regardless
of whether patients developed rhinosinusitis.
Conclusion: Sinonasal preservation during TSH is asso-
ciated with a low rate of postoperative rhinosinusitis re-
quiring FESS and excellent long-term patient reported out-
comes. We continue to advocate for sinonasal preservation
during pituitary surgery. 
C 2019 ARS-AAOA, LLC.
Key Words:
chronic rhinosinusitis; endoscopic endonasal approach to
the pituitary; endoscopic minimally invasive surgery of the
skull base; endoscopic; skull-base surgery; endoscopic si-
nus surgery; sinusitis; SNOT-22
How to Cite this Article:
Rimmer RA, Vimawala S, Chitguppi C, et al. Rate of rhinos-
inusitis and sinus surgery following a minimally destruc-
tive approach to endoscopic transsphenoidal hypophysec-
tomy. Int Forum Allergy Rhinol. 2019;00:1-7.
T he endoscopic endonasal approach to transsphenoidal
hypophysectomy (TSH) has largely supplanted the tra-
ditional microscopic approach, with proponents citing im-
proved visualization, more complete tumor removal, and
better patient outcomes.1, 2 The endoscopic approach re-
quires creation of a sinonasal corridor for access to the skull
base. Initial experience with endonasal endoscopic skull-
base surgery was focused on safety and less concern was
given to preservation of sinonasal function. However, now
that safety has largely been established, there remains wide
variation among surgeons regarding the degree of sinonasal
preservation during the approach.3–5
At our institution, we favor a “minimally destructive” ap-
proach to TSH emphasizing preservation of normal struc-
tures. Our standard technique involves lateralization of
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 1
Rimmer et al.

FIGURE 1. “1.5” sellar approach. A large, right-sided sphenoidotomy
(“1.0”) for working instruments together with a smaller left-sided mucosal
sphenoidotomy (“0.5”) for the endoscope. A wide bony sphenoidotomy is
performed submucosally bilaterally. Both sphenopalatine vascular pedicles
are elevated off the sphenoid face and maintained.
FIGURE 2. “Tunnel” approach. Septal flap is elevated through hemitrans-
fixion to perform septoplasty. Bony sphenoidotomy created within septal
tunnel with contralateral pushdown mucosal sphenoidotomy.

outcomes. This study seeks to identify the rates of postoper-

ative rhinosinusitis, and particularly those patients requir-
turbinates, as opposed to resection, along with a limited
ing postoperative FESS following our minimally destructive
(usually 1 cm) posterior septectomy. We have described a
approach to TSH.
“1.5” technique, which involves an ipsilateral wide sphe-
noidotomy with a pushdown technique on the working
instrument side (“1”) combined with a limited contralat-
eral mucosal sphenoidotomy (“0.5”) for the endoscope Patients and methods
(Fig. 1).6 Despite the mucosal preservation, there is com- We performed a retrospective chart review of patients un-
plete submucosal removal of the bony sphenoid face bilat- dergoing TSH at our institution from 2005 to 2018 for
erally. This approach preserves the sphenopalatine arteries pituitary adenomas undergoing our “1.5” or “Tunnel”
bilaterally should a nasoseptal flap (NSF) be needed; how- approach. Patient charts were reviewed for demographic
ever, we do not routinely raise NSFs. In the setting of ob- information, operative reports, and postoperative follow-
structive septal deflection, a septoplasty can be performed up examinations in accordance with Institutional Review
through a standard hemitransfixion incision while simul- Board (IRB) policies.
taneously providing a submucosal “tunnel” to perform a
wide bony sphenoidotomy with mucosal pushdown on the
working instrument side (Fig. 2).6 We feel that these ap-
proaches allow us to minimize sinonasal morbidity without
compromising tumor resection (Fig. 3).
The rate of rhinosinusitis following endoscopic TSH
varies widely in the literature. Studies can be difficult to
compare because of differences in technique, sample size,
and patient comorbidities.7–12 Aggressive turbinate resec-
tions, ethmoidectomies, and extensive sphenoidotomies are
unnecessary for TSH approach in otherwise nondiseased si-
nuses. It has been argued that this approach may result in FIGURE 3. Endoscopic view of postoperative nasal cavity 3 weeks after TSH
more adhesions, obstruction, and rhinosinusitis.13 We hy- using 1.5 approach. (A). Right nasal cavity looking into sphenoidotomy via
“1.0” working side with pushdown preserving branches of sphenopalatine
pothesize that our approach, focused on sinonasal preser- artery. (B). Left nasal cavity with “0.5” sphenoidotomy for scope. Note the
vation, will lead to decreased nasal morbidity with low preservation of normal structures, intact mucosa, and lack of crusting. TSH =
rates of postoperative rhinosinusitis and excellent patient transsphenoidal hypophysectomy.

2 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019
 Sinusitis post–endoscopic transsphenoidal surgery

TABLE 1. Characteristics of patients who developed post-TSH rhinosinusitis compared to those who did not develop
rhinosinusitis

Rhinosinusitis within 3 months Rhinosinusitis after 3 months No post-TSH rhinosinusitis

Characteristic (N = 58) (N = 26) (N = 331) p

Gender, n (%)
Male 32 (55) 11 (42) 174 (53) 0.539
Female 26 (45) 15 (58) 157 (47)
Age (years), mean ± SD 51.4 ± 13.0 48.7 ± 15.5 54.8 ± 15.7 0.06
BMI (kg/m ), mean ± SD
2
32.2 ± 6.6 34.3 ± 8.9 30.4 ± 6.8 0.009
History of cigarette smoking, n (%) 25 (43) 9 (35) 119 (36) 0.559
History of sinusitis, n (%) 17 (29) 5 (19) 51 (15) 0.039
FESS during TSH, n (%) 9 (16) 4 (15) 33 (10) 0.282
Secreting tumor, n (%) 15 (26) 12 (46) 72 (22) 0.023
Duration of follow-up (months), mean ± SD 34.1 ± 22.0 46.8 ± 25.9 29.5 ± 26.1 0.003
Approach (tunnel vs 1.5), n (%)
Tunnel 14 (24) 9 (35) 112 (34) 0.361
1.5 approach 44 (76) 17 (65) 219 (66) 0.361
Reconstruction, n (%)
Surgicel
R
4 (7) 10 (38) 90 (27) <0.001

Surgicel R
+ DuraSeal 1 (2) 0 9 (3) 1
Dural substitutes + DuraSeal 44 (76) 14 (54) 204 (62) 0.064
Nasoseptal flap + dural substitute 9 (15) 2 (8) 26 (8) 0.178
Fascia 0 0 2 1

BMI = body mass index; FESS = functional endoscopic sinus surgery; SD = standard deviation; SNOT-22 = 22-item Sino-Nasal Outcome Test; TSH = transsphenoidal
hypophysectomy.

Post-TSH rhinosinusitis was broadly defined as endo-
scopic evidence of rhinosinusitis (eg, mucosal edema, mu-
copurulent drainage) and prescription of antibiotics during
a postoperative visit at any time point following TSH.
All TSH’s were performed as combined cases with 1 of 3
faculty otolaryngologists and 1 of 2 faculty neurosurgeons.
Preoperatively, the skin of the face and nasal cavity is not
prepared with antiseptic solution; however, if needed, sites
for grafts such as fascia lata are prepared in standard ster-
ile fashion. At the conclusion of the case, a half piece of
Nasopore R
(Stryker Corporation, Kalamazoo, MI) biore-
sorbable foam dressing is routinely placed in each middle
meatus to medialize the middle turbinate. Patients gener-
ally receive 2 to 3 doses of perioperative cefazolin while
inpatient but are not routinely discharged on antibiotics.
Postoperative steroids are administered as dictated by en-
docrinology and neurosurgery. All patients were seen at
regular postoperative intervals, typically 1 week, 1 month,
3 months, and annually thereafter, for office debridement
and follow-up.
All statistical analysis was performed using IBM SPSS
Statistics software for Macintosh, Version 26.0 (IBM Corp,
Armonk, NY). Univariate analysis was performed using
Fisher’s exact test and chi-square analysis between 2 cate-
gorical variables. Analysis of variance (ANOVA) analysis
was performed for continuous and categorical variables.
Tukey’s honestly significant difference (HSD) was used for
subgroup analysis on all ANOVA analysis with p < 0.20. A
p value of <0.05 was considered to be a significant finding.
Results
We identified 415 patients meeting inclusion criteria. Of
these patients, 58 (14%) were identified as developing
an episode of post-TSH rhinosinusitis within 3 months,
whereas 26 patients (6%) developed rhinosinusitis after
3 months. Only 6 patients (1.4%) ultimately underwent
post-TSH FESS.
Demographics were comparable among patients who de-
veloped post-TSH rhinosinusitis and those who did not
(Table 1). Patients with post-TSH rhinosinusitis within
3 months, were significantly more likely to have a pre-
operative history of chronic or recurrent acute rhinosi-
nusitis. There was a higher incidence of secreting tumors

International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 3
Rimmer et al.
TABLE 2. Average SNOT-22 scores and average changes in SNOT-22 scores
Post-TSH rhinosinusitis
SNOT-22 score interval
Average preoperative
Average initial postoperative
Average last postoperative
Average difference preoperative to initial postoperative
Average difference initial postoperative to last postoperative
Average difference preoperative to last postoperative
SNOT-22 = 22-item Sino-Nasal Outcome Test; TSH = transsphenoidal hypophysectomy.
in the group who developed post-TSH rhinosinusitis after
3 months. The most common functional tumor was growth
hormone–secreting, followed by adrenocorticotropic hor-
mone (ACTH)-secreting, followed by prolactinomas. Dif-
ferences in body mass index (BMI, kg/m2 ) between the
group who developed rhinosinusitis after 3 months and pa-
tients without rhinosinusitis were significant. The length of
follow-up for the group with rhinosinusitis after 3 months
also reached statistical significance when compared to the
group without sinusitis. The average follow-up for pa-
tients who developed rhinosinusitis within 3 months was
34 months, 47 months for those with rhinosinusitis after
3 months, and 29.5 months for those who did not develop
rhinosinusitis.
Most patients had sellar reconstruction with oxidized cel-
lulose polymer (Surgicel R
; Ethicon Inc., Somerville, NJ) or
synthetic dural substitutes (376) vs NSF plus synthetic du-
ral substitute (37). There were significantly fewer patients
with oxidized cellulose polymer reconstruction who devel-
oped rhinosinusitis within 3 months, compared to the other
groups. Otherwise, there were no statistically significant
differences in reconstruction techniques between patients
who developed postoperative rhinosinusitis and those who
did not.
Description of patients with postoperative sinusitis
Patients predominantly experienced post-TSH acute rhi-
nosinusitis. Excluding patients who ultimately underwent
post-TSH FESS, 95% of patients who met our definition
of post-TSH acute rhinosinusitis were successfully treated
with 1 or 2 courses of antibiotics, and only 4 patients re-
ceived a maximum of 3 courses of antibiotics. Average time
from TSH to antibiotic treatment for rhinosinusitis was
5.4 months. The large majority of rhinosinusitis was re-
ported as involving the sphenoid sinus (81%), followed by
the middle meatus (13%), and was unspecified in 6%.
Four patients who developed post-TSH acute rhinosi-
nusitis had undergone FESS prior to TSH. One of these
patients was found to have acute rhinosinusitis at the
time of planned TSH, so FESS was performed and TSH
was staged for a later date. Thirteen (15%) patients who
4 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019
No post-TSH rhinosinusitis
(N = 84) (N = 331) p
21.7 (n = 40) 17.5 (n = 153) 0.191
34.9 (n = 66) 29 (n = 246) 0.051
19.4 (n = 57) 14.7 (n = 223) 0.068
15.6 (n = 40) 13.6 (n = 146) 0.571
−16.6 (n = 56) −14.7 (n = 205) 0.477
−3.8 (n = 37) −2.4 (n = 132) 0.732
developed post-TSH acute rhinosinusitis underwent FESS
concurrently with TSH, which was not statistically differ-
ent from the rate of concurrent FESS in patients who did
not develop post-TSH acute rhinosinusitis.
Most (73) patients with post-TSH acute rhinosinusitis
did not undergo NSF reconstruction. There was a higher
percentage of NSFs in the group who developed rhinosi-
nusitis within 3 months; however, this difference did not
reach statistical significance. Of 11 patients with NSFs, all
were managed medically with antibiotics (Table 1).
There were no intracranial infectious complications in
any patients who developed post-TSH sinusitis.
Preoperative SNOT-22 scores were available for 47% of
patients who developed post-TSH acute rhinosinusitis. The
average pre-TSH SNOT-22 score was 21.7 (range, 0 to
79). SNOT-22 scores increased an average of +15.6 points
(range, −36 to +62 points) at the first post-TSH follow-
up. However, the most recent SNOT-22 score within
the follow-up period actually decreased an average of
5.2 points (range, −60 to +62 points) from the preopera-
tive score (Table 2).
A similar percentage (46%) of preoperative SNOT-22
scores was available for patients who did not develop
post-TSH acute rhinosinusitis. The average preoperative
SNOT-22 score for these patients was 17.5 (range, 0 to 81).
Postoperative scores were available for 75.2% of patients
who did not develop post-TSH acute rhinosinusitis. The
average first postoperative SNOT-22 score was 29.0 (range,
0 to 87) and the average difference between preoperative
and first postoperative SNOT-22 score was +13.6 (range,
−46 to +67). The last available postoperative SNOT-22
score was 14.7 (range, 0 to 99). The average difference be-
tween initial postoperative SNOT-22 to last postoperative
SNOT-22 score was −15.2 (range, −83 to 42).
Using paired t test, the differences in SNOT-22 scores
were compared between the preoperative, first postopera-
tive, and most recent postoperative scores (Table 3). Among
the group who developed post-TSH acute rhinosinusitis,
the differences in SNOT-22 scores were significant between
preoperative and first postoperative, and between first post-
operative and last follow-up scores. The difference between
preoperative and last follow-up SNOT-22 did not reach

TABLE 3. Statistical significance of change in SNOT-22
scores
SNOT-22 score interval
Post-TSH rhinosinusitis
Difference preoperative to initial postoperative
Difference initial postoperative to last postoperative
Difference preoperative to last postoperative
No post-TSH rhinosinusitis
Difference preoperative to initial postoperative
Difference initial postoperative to last postoperative
Difference preoperative to last postoperative
SNOT-22 = 22-item Sino-Nasal Outcome Test; TSH = transsphenoidal hypophy-
sectomy.
TABLE 4. Characteristics of patients undergoing post-TSH
FESS
Characteristic
Male, n
Female, n
Age (years), average (range)
2
BMI (kg/m ), average (range)
History of cigarette smoking, n
History of rhinosinusitis, n (%)
History of prior FESS, n (%)
FESS at time of TSH, n (%)
Time to FESS (months), average (range)
Follow-up (months), average (range)
BMI = body mass index; FESS = functional endoscopic sinus surgery; TSH =
transsphenoidal hypophysectomy.
statistical significance, reflecting a return to baseline.
Among the group who did not develop rhinosinusitis, sta-
tistical significance was reached for all comparisons.
Description of patients who underwent post-TSH
FESS
Six (1.4%) patients underwent post-TSH FESS. Patient de-
mographics and characteristics are listed in Table 4. Of
these patients, most were reconstructed with synthetic dural
substitute (5) or Surgicel
R
(1). No patients who underwent
post-TSH FESS had received an NSF.
Three (50%) of these patients had a documented history
of prior rhinosinusitis (2 patients had histories of chronic
rhinosinusitis without polyposis, 1 patient had a maxillary
fungal mycetoma) and 1 of these patients underwent FESS
at another institution prior to TSH.
Sinusitis post–endoscopic transsphenoidal surgery
Two patients simultaneously underwent revision TSH for
residual tumor at the time of post-TSH FESS—in these cases
recurrent tumor served as the primary reason for surgery.
p One of these patients had been treated with 2 courses of an-
tibiotics for acute rhinosinusitis. The other patient suffered
from prolonged symptoms consistent with chronic rhinos-
<0.001 inusitis without polyposis and was treated with 7 courses
<0.001 of antibiotics prior to revision surgery. This patient was
resistant to additional surgery but ultimately consented for
0.322
combined FESS and transsphenoidal resection of residual
pituitary tumor.
<0.001 One patient who developed an episode of post-TSH acute
rhinosinusitis successfully managed with 1 course of antibi-
<0.001
otics was noted to have an ethmoid mucocele on imaging
0.045 after 2 years and was successfully treated with post-TSH
FESS. Another patient with recurrent acute rhinosinusitis
with persistent symptoms despite antibiotic therapy was
noted to have an obstructive sphenoid scar band nearly
19 months postoperatively and was definitively treated with
post-TSH FESS. Of the 2 remaining patients, 1 patient had
post-TSH acute rhinosinusitis treated with antibiotics on
Value 2 separate occasions, and symptoms of nasal obstruction.
On exam, he was noted to have a septal deflection and ob-
3 struction of the middle meatus. He was treated with post-
3 TSH FESS and septoplasty. The other patient developed
recurrent acute rhinosinusitis with at least 6 sinus infec-
51 (40–58)
tions in the year following TSH.
30.2 (21.9–39.8) Average time from TSH to FESS was 26.3 months (range,
0 8.5 to 78 months), and average follow-up was 60.2 months.
Patients received an average of 2.8 courses of antibiotics
3 (50)
(range, 1 to 7 courses) prior to undergoing FESS.
1 (17)
1 (17) Discussion
26.7 (8.5–78) The endoscopic approach to TSH is now more widely ac-
56.8 (16–94) cepted than the traditional microscopic technique because it
affords better visualization and improved rates of gross to-
tal resection.1 The transition to endoscopic TSH has led to
wide variation in technique, with significant differences in
the degree of sinonasal preservation.3 At our institution, we
advocate for a minimally destructive approach. Our “1.5”
technique involves inferior and middle turbinate lateraliza-
tion instead of resection, a small posterior septectomy, and
preservation of sphenopalatine arteries bilaterally by using
a pushdown technique on the working side and a limited
mucosal sphenoidotomy on the endoscope side. Routine
resection of turbinates is avoided because we feel that vi-
sualization and access is frequently not compromised with
lateralization. Turbinates perform important roles in phys-
iologic nasal function by helping to humidify, warm, and
filter airflow, in addition to their role in olfaction.4 Further-
more, once medialized following surgery, turbinates pro-
vide mechanical protection against inadvertent postopera-
tive instrumentation of the skull-base defect (eg, nasogastric
tube placement).
The rate of developing an episode of post-TSH acute
rhinosinusitis that required treatment in this retrospective
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 5
Rimmer et al.
study was 14% (within 3 months) and 6% (after 3 months).
The rate of rhinosinusitis following TSH varies widely in
the literature.7–12 Linsler et al.,7 using a patient-reported
survey of sinonasal outcomes following a mono-nostril
TSH technique using a speculum and endoscope, reported a
rate of postoperative recurrent acute rhinosinusitis of 25%
at 1 year and 11.4% of patients requiring additional nasal
surgery for nasal obstruction or rhinosinusitis. Batra et al.8
reported a 7.5% rate of sphenoid sinusitis following TSH,
whereas Gondim et al.11 showed a 1.66% rate of sphenoid
sinusitis in 301 patients undergoing TSH. Given the range
of reported outcomes, it can be difficult to draw compar-
isons between studies because of differences in sample size,
study design, and surgical technique.
Our reported rate is heavily influenced by our defini-
tion of rhinosinusitis, which required endoscopic evidence
(eg, inflammation, mucopurulent drainage) along with pre-
scription of antibiotics. Many of these patients did not have
endoscopically guided cultures, thus it is difficult to ascer-
tain whether they developed an episode of acute viral or
bacterial sinusitis. Our institutional preference for more
liberal use of antibiotics in the postoperative period can be
explained by increased caution in the setting of skull-base
surgery. Overall, this likely overestimated the incidence of
true postoperative sinusitis in this population.
Although we did not place postoperative timeframe limits
on our detection of sinusitis, we divided patients who devel-
oped rhinosinusitis into groups based on whether treatment
occurred before or after 3 months. This categorization was
an effort to identify patients with acute rhinosinusitis more
likely related to postoperative sequelae, vs patients develop-
ing potentially unrelated rhinosinusitis on extended follow-
up. The 3-month time period was selected because we feel it
gives ample time for debridement and allows nasal mucosa
to return to a baseline. We did note that patients who devel-
oped sinusitis within 3 months post-TSH had a significantly
higher likelihood of having a history of recurrent acute or
chronic rhinosinusitis without polyposis. Overall, the av-
erage time to identification and treatment of postoperative
rhinosinusitis in our series was 5.4 months (range, 6 days to
48 months). In cases where patients developed rhinosinusi-
tis several months following TSH, the actual contribution
of surgery to the development of sinusitis is questionable.
The benefit of sinonasal preservation is highlighted in
the improved SNOT-22 scores identified at last follow-up.
Scores were either not statistically different or statistically
less than preoperative scores. This underscores the preser-
vation of nasal function with our approach. McCoul et al.14
showed a similar trend in their series of patients under-
going endoscopic skull-base surgery, noting that SNOT-
22 scores showed a statistically significant increase within
3 weeks postoperatively, but no significant difference from
preoperative scores after 6 weeks. Our data shows a similar
trend, although our average SNOT-22 score at last follow-
up was slightly less.
There were no significant infectious complications sec-
ondary to post-TSH rhinosinusitis. Only a very small
6 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019
minority (1.4%) of patients eventually required post-TSH
FESS. The fact that most post-TSH acute rhinosinusitis is
managed medically may simply highlight the transient na-
ture of postoperative mucosal edema contributing to pos-
tobstructive acute rhinosinusitis in this population.
FESS was concurrently performed at the time of TSH in
15% of patients who developed post-TSH rhinosinusitis,
compared to 10% of patients without post-TSH rhinosi-
nusitis, which did not reach statistical significance. In cases
of chronic rhinosinusitis or a history of recurrent acute rhi-
nosinusitis in the absence of active infection, we believe it is
safe to perform FESS concurrently with TSH.15 However,
in the presence of acute bacterial infection or presence of
fungal mycetoma, it is advised to medically treat the patient
or perform staged FESS prior to TSH.15
Significant differences in BMI were noted between
patients who developed post-TSH rhinosinusitis after
3 months (mean BMI 34.3 kg/m2 ) and those who did not
develop post-TSH rhinosinusitis (mean BMI 30.4 kg/m2 ).
Both average BMIs are considered “obese” and multiple
studies have demonstrated obesity to be a common co-
morbidity in patients with chronic rhinosinusitis. Although
a causal relationship has not been determined, both obe-
sity and chronic rhinosinusitis are characterized by chronic
inflammation.16, 17 In our series, it is difficult to assign spe-
cific meaning to a 4-point elevation in average BMI. How-
ever, both rhinosinusitis groups had average BMIs that
were higher than the group without rhinosinusitis, which
may point to the association between obesity, inflamma-
tion, and a predilection for sinusitis.
Significant differences were also noted in the presence of
secreting tumors within the group with rhinosinusitis after
3 months compared to the group without rhinosinusitis.
When both rhinosinusitis groups were combined and com-
pared to patients without rhinosinusitis, there was no statis-
tically significant difference (p value = 0.062). Other stud-
ies have shown no difference in the rate of rhinosinusitis
for secreting vs nonsecreting tumors.18 Growth hormone–
secreting tumors were more common than ACTH-secreting
tumors or prolactinomas in all groups. Anatomical changes
associated with acromegaly and the resultant increased dis-
section and surgical difficulty may contribute to a predis-
position for rhinosinusitis in these patients.19 Furthermore,
Cushing’s disease may lead to increased rates of comor-
bid obesity and diabetes mellitus, which can contribute to
inflammation associated with chronic rhinosinusitis.17
In our series, the Surgicel R
reconstruction technique
had the lowest rate of post-TSH rhinosinusitis (13% of
Surgicel R
reconstructions resulted in rhinosinusitis). This
technique is employed when there is no intraoperative cere-
brospinal fluid leak and the patient is not expected to re-
ceive continuous positive airway pressure (CPAP) therapy.
Cases utilizing this reconstruction may have involved less
dissection and subsequently less trauma to the nasal cavity,
which may partially explain its lower rate of rhinosinusi-
tis. To our knowledge there are no other studies assess-
ing development of rhinosinusitis following this technique.
 Sinusitis post–endoscopic transsphenoidal surgery

Dural substitute with dural sealant glue was by far the
most commonly performed reconstruction technique and
resulted in a 17% rate of rhinosinusitis at 3 months, but
only a 6% rate of rhinosinusitis after 3 months. A com-
parison of dural substitutes and autologous mucosal grafts
for sellar reconstruction found no difference in postopera-
tive sinusitis between the 2 techniques,18 and we prefer to
limit the morbidity associated with harvesting grafts. NSFs
were not as commonly performed as either of the previous
techniques, but did result in a proportionally higher rate
of post-TSH rhinosinusitis per our definition. Given the ex-
tensive dissection and manipulation associated with harvest
and placement of NSFs, this higher rate is not surprising,
and reported rates vary widely in the literature.13, 20 Im-
portantly, no patients who received NSFs required revision
FESS at a later date.
We acknowledge the limitations of this retrospective
study. Our definition of rhinosinusitis was broad and an-
tibiotic use was relatively liberal in the setting of skull-base
surgery, so we are likely overestimating the incidence of
true acute rhinosinusitis in this population. Data points
were heavily reliant on clinical documentation including
patient-reported medical histories, description of in-office
examinations, and documentation of treatment. Preopera-
tive and postoperative SNOT-22 scores were not available
for all patients, although we feel that the trends in scores
are likely still accurate. There is potential that complica-
tions may not be captured due to lack of patient follow-up;
however, follow-up averaged greater than 2 years for all pa-
tients, and over 3 years for those who developed post-TSH
rhinosinusitis (average 38 months; range, 2 to 118 months),
likely capturing complications in the perioperative period.
Conclusion
Sinonasal preservation during endoscopic TSH limits sur-
gical morbidity, reduces risk of long-term complications,
and allows preservation of the NSF. Postoperative rhinos-
inusitis may develop in a minority of cases and can be
effectively managed with antibiotics; ESS is rarely needed.
Patients with histories of recurrent acute or chronic rhinos-
inusitis are at higher risk, and careful selection for staged
or concurrent FESS at the time of TSH may help to limit
postoperative rhinosinusitis.

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