Endoscopic Image‐Guided Transethmoid Pituitary Surgery
Authors: Thomas Roy F. , Monacci William T. , Mair Eric A. 
Published: February 2003

OBJECTIVEWe describe a new endoscopic transethmoid approach for pituitary surgery and to compare it with other surgical techniques.STUDY DESIGN AND SETTINGEleven patients undergoing pituitary surgery from September 2000 through January 2002 underwent an image‐guided endoscopic transethmoid procedure to remove pituitary tumors. Ease of approach, resection, exposure of the surgical field, and operative complications were documented.RESULTSEndoscopic ethmoidectomy permits enhanced exposure and simplified tumor resection. The use of one nostril to stabilize the endoscope and the other to pass instruments affords a bimanual procedure that avoids the difficulty of small nares and keeping the scope fixed while exchanging instruments. Operative morbidity was low with no significant complications in this pilot study.CONCLUSIONSThis approach opens a generous operative exposure while safely allowing room to endoscopically maneuver and affords direct access should revision surgery be needed.SIGNIFICANCEThis procedure uses a technique familiar to otolaryngologists and may be used for pituitary and other skull base tumors.The transseptal approach to the sella turcica is the most commonly performed procedure to reach the pituitary gland. Three major variations of the transseptal approach are used: sublabial approach, external rhinoplasty approach, and transnasal approach. Each has unique advantages and disadvantages relative to each other and the endoscopic procedure, apart from the shared transseptal route (Table 1). The techniques have been described elsewhere previously.1–3 More recently, endoscopy has been used to aid the approach to the pituitary.

Sublabial
External rhinoplasty
Transnasal
Standard endoscopy
Transethmoid endoscopy

Transseptal dissection
Yes
Yes
Yes
Varies†
No

Self‐retaining speculum
Yes
Yes
Yes
Yes†
No

External incision
No
Yes
No
No
No

Operating microscope
Yes
Yes
Yes
Varies†
No

Stereoscopic vision
Yes
Yes
Yes
No
No

Nasal packing
Yes
Yes
Yes
Varies
No

Septal perforation (estimated incidence∗)
7.1%
19%
8%
No data
No data

Dental paresthesias∗
22%
14%
13%
None
None

Cosmetic complications∗
Tip ptosis
Columeller deformity 2%
Alar tears 9%
None
None

From Dew et al,1 Eisele et al,2 Koltai et al,3 and Schoem et al.15
Varies depending on individual operating technique.

The first endoscopic procedures used the transseptal dissection route through a standard sublabial incision, with the endoscope passed through a self‐retaining speculum.4–6 In other cases the endoscope was used for the approach only, with the binocular operating microscope subsequently used for the tumor resection.7 Except for the wide field of vision afforded by the endoscopic approach, the morbidity of a transseptal dissection remained. More recent advances have used an endonasal approach, which allows the surgeon to bypass the transseptal dissection.8–11 The majority of procedures performed use one nostril to pass the endoscope and other instruments, with limited endoscopic operative maneuverability. We introduce an endonasal transethmoid approach bypassing the need for a nasal retractor, headrest, and postoperative nasal packing, while providing enhanced endoscopic operative maneuverability through bimanual instrumentation using both nares and an endoscope stabilizer.