The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Olfactory Changes After Endoscopic Endonasal Transsphenoidal Approach for Skull Base Tumors Boo-Young Kim, MD; Seok-Gu Kang, MD, PhD; Sung W. Kim, MD, PhD; Yong K. Hong, MD, PhD; Sin-Soo Jeun, MD, PhD; Soo W. Kim, MD, PhD; Hyun B. Kim, MD; Min Kim, MD; Jae H. Maeng, MD; Dong C. Lee, MD; Jin H. Cho, MD, PhD; Yong J. Park, MD, PhD Objectives/Hypothesis: The increased number of endoscopic endonasal transsphenoidal approaches (EETSA) has been associated with sinonasal complications such as olfactory dysfunction. Current studies have compared preoperative and postoperative olfactory function according to surgical type and age. Study Design: Retrospective review of medical records at a tertiary referral center. Methods: Patients were divided into two groups according to surgical type and into four groups according to age. The two surgical groups were defined based on the bilateral nasoseptal flap technique (group A: right conventional nasoseptal flap and left modified nasoseptal rescure flap; group B: bilateral modified nasoseptal rescue flap). The four age groups were 30, 31–45, 46–60, and 61 years. Patients underwent preoperative olfactory function evaluation using a visual analogue scale (VAS), the Connecticut Chemosensory Clinical Research Center Test (CCCRC), and the Cross-Cultural Smell Identification Test (CCSIT). Repeat testing was performed 6-months postoperatively. Results: A total of 226 patients who underwent binostril four-hand EETSA were included in this study. In both groups A and B, the olfactory function was significantly decreased according to CCCRC and CCSIT scores (P < 0.05). The VAS scores were significantly decreased in both groups (P < 0.05). The symptom scores and olfactory test results were significantly changed in >30-year-old patients who had undergone EETSA. Conclusion: EETSA might contribute to olfactory dysfunction independent of surgery type. In addition, age may affect the restoration of olfaction after EETSA. Patients who plan to undergo EETSA must be informed that their olfaction may be impaired. Key Words: Nasal symptom, endoscope, transsphenoidal approach, skull base tumor, olfactory change, age. Level of Evidence: 4. Laryngoscope, 124:2470–2475, 2014
INTRODUCTION The transsphenoidal route for anterocentral skull base surgery1 has been the standard surgical treatment for sellar tumors,2 and the use of the binostril four-hand endoscopic endonasal transsphenoidal approach (EETSA) for skull-base lesions has increased.3 Although outcomes are comparable with those of traditional transsphenoidal approaches, EETSA is associated with relatively low complication rate.4 However, the increase in the number of EETSA procedures has been associated with several sinonasal complications such as olfactory
From the Department of Otolaryngology–Head and Neck Surgery (B-Y.K., SUNG W.K., SOO W. K., H.B.K., M.K., M.J.H., D.C.L., J.H.C., Y.J.P.); the Department of Neurosurgery (S-G.K., Y.K.H., S-S.J.); the Minimal Access and Robotic Surgery Center, Seoul St. Mary’s Hospital (SUNG W.K., S-S.J.); and the Department of Biomedical Science (SUNG W.K., S-S.J.), The Catholic University of Korea, College of Medicine, Seoul, Korea Editor’s Note: This Manuscript was accepted for publication March 5, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Sung Won Kim, MD, PhD, Department of Otolaryngology–Head and Neck Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul, 137–701, Korea. E-mail: [email protected] DOI: 10.1002/lary.24674
Laryngoscope 124: November 2014
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dysfunction because of the resection of anatomical structures known to contain olfactory neuroepithelium.5,6 In our previous studies, the symptom scores of olfactory change increased significantly after EETSA (P < 0.05).7 However, an subjective diminution of olfactory function undergoing EETSA has been poorly documented in previous literature involving small populations. Therefore, we investigated the distinction between preoperative and postoperative olfactory function using a visual analogue scale (VAS), the Connecticut Chemosensory Clinical Research Center test (CCCRC), and the Cross-Cultural Smell Identification Test (CCSIT). The present study was performed to compare preoperative and postoperative olfactory function according to surgery type (representative of the extent of olfactory mucosal damage) and patient age to estimate the regenerative ability of the olfactory neuroepithelium.
MATERIALS AND METHODS Between February 2009 and October 2012, a total of 285 patients with anterocentral skull-base tumors including pituitary adenoma underwent operations via EETSA at Seoul St. Mary’s Hospital, The Catholic University of Korea. Of these, 226 were completely followed up by olfactory function evaluation for at least 6 months postoperatively.
Kim et al.: Olfactory Changes After Binostril Four-Hand Approach
All patients underwent nasal endoscopic examination and paranasal sinus computed tomography (CT), and those who showed abnormalities in the sinonasal space were excluded. Patients with previous nasal or sinus surgery, history of asthma, or sinonasal diseases were excluded. We also excluded the pateints with a history of olfactory disturbance before EETSA. Patients were divided into two groups according to the surgical approach: group A, right conventional nasoseptal flap and left modified nasoseptal rescue flap; and group B, bilateral modified nasoseptal rescue flaps.8,9 Patients were also divided to four groups according to age: 30 years (n 5 42), 31–45 years (n 5 60), 46–60 years (n 5 71), and 61 years (n 5 53).10 Patients underwent preoperative olfactory function evaluation using VAS, CCCRC, and CCSIT to address olfactory difficulty. Repeat testing was performed 6 months postoperatively.
Surgical Technique Group A: Right conventional nasoseptal flap and left modified nasoseptal rescue flap9. The procedures to harvest bilateral nasoseptal flap were as follows. First, the flap was designed on the right side of the nasal septum. With monopolar sharp electrocautery, one incision was made from the inferior border of the sphenoidal sinus ostium following the sagittal plane of the septum, 1 cm below the most superior aspect of the septum; and a parallel incision was made over the vomer, palatine crest, and maxillary crest. These incisions were joined anteriorly by a vertical incision made with a no. 15 blade scalpel in the area opposite the caudal end of the inferior turbinate. Mucoperichondrial and mucoperiosteal flaps were developed from the right side of the bony nasal septum with Cottle, Freer, and hockey-stick-shaped elevators (Karl Storz GmbH & Co. KG, Tuttlingen, Germany). At the anterior face of the sphenoid, the flap was elevated more carefully to preserve a posterolateral neurovascular pedicle. The right ostium of the sphenoidal sinus was widened superiorly and inferiorly with a rongeur. After elevating the right pedicled septal mucosal flap, we performed a posterior septectomy that included a portion of the perpendicular plate of the ethmoid bone (PPE), the vomer, and the anterior wall of the sphenoidal sinus. During that surgical procedure, we tried to remove bony material as an en bloc for use in the reconstruction of the sellar floor. After the posterior septectomy, the sellar floor was visible. The left modified nasoseptal rrescue flap was designed along the line of removed septal bone. After harvesting, both nasoseptal flaps were displaced into the nasopharynx during the extirpative phase of the surgery to avoid any injury affecting the potential use of those flaps. Mucosal bleeding was controlled with 1:100,000 epinephrine-soaked cotton pledgets and Surgicel (Ethicon; Johnson & Johnson, Somerville, NJ), and major bleeding was controlled with suction electrocautery and a collagen hemostatic agent. We reconstructed the surgical defect using a multilayer technique after removal of tumor. First, the vomer or the PPE was placed in the bony defect as a rigid buttress in cases with CSF leakage. The reflected sphenoidal sinus mucosa was repositioned to cover the operative site. When CSF leakage was suspected after inserting a bony buttress graft with the Valsalva maneuver (anesthetic bagging), we used the right nasoseptal flap to cover the bone graft. The right nasoseptal flap was rotated to cover the defect and overlap the bony edge of the surgical defect. To facilitate attachment of the flap and prevent mucocele formation, the surrounding mucosa was stripped before flap application. The left modified nasoseptal rescue flap was used when excessive sphenoidal mucosa was removed. The
Laryngoscope 124: November 2014
denuded sphenoidal sinus was covered with the left modified nasoseptal rescue flap. Unused flaps were repositioned in the original sites, and unused septal bone resected en bloc was inserted between the bilateral nasoseptal flaps. The right flap was repositioned and the incisions were closed with 5-0 polydioxanone (PDS) sutures. The left flap was repositioned without suturing. Group B: Bilateral modified nasoseptal rescue flaps8. The procedure to harvest the bilateral modified nasoseptal rescue flaps was as follows. First, the flap was designed on the right side of the nasal septum. With monopolar sharp electrocautery, a curvilinear incision was made from the inferior border of the sphenoidal sinus ostium following the sagittal plane of the septum. This incision was made anteriorly toward the level of one-half to one-third the height of the middle turbinate over the vomer to preserve the nasoseptal pedicle. This incision was the main distinction between a conventional nasoseptal flap and a modified nasoseptal rescue flap. A mucoperiosteal flap was developed from the right side of the bony nasal septum with Cottle and hockey stick elevators. At the anterior face of the sphenoid, the flap was elevated more carefully to preserve the posterolateral neurovascular pedicle. The right ostium of the sphenoidal sinus was widened superiorly and inferiorly with a rongeur. After elevating the right modified nasoseptal rescue flap, the posterior bony septum that included a portion of the perpendicular plate of the ethmoid bone, the vomer, and the anterior wall of the sphenoidal sinus was removed. During the surgical procedure, we tried to remove the bony material en bloc for use in the reconstruction of the sellar floor. After this procedure, we could identify the sellar floor. The left modified nasoseptal rescue flap was designed along the line of the removed septal bone. Both modified nasoseptal rescue flaps were then displaced into the nasopharynx during the extirpative phase of the surgery to avoid any injury affecting the potential use of those flaps. Simultaneous septoplasty was performed with no additional incision in patients with nasal septal deviation, which would cause narrowing of the nasal cavities to hinder manipulation of the endoscope. Mucosal bleeding was controlled with 1:100,000 epinephrinesoaked cotton pledgets and an absorbable hemostat (Surgicel, Ethicon; Johnson & Johnson, Somerville, NJ); and major bleeding was controlled with suction electrocautery and a collagen hemostatic agent. Unused modified nasoseptal rescue flaps were repositioned in the original sites, and unused septal bone resected en bloc was inserted between the bilateral modified nasoseptal rescue flaps to strengthen the repositioned bilateral modified nasoseptal rescue flaps. Both modified nasoseptal rescue flaps were repositioned without suturing. The VAS evaluated olfactory difficulty and was used to assess preoperative and postoperative subjective olfactory symptoms. It was scored from 0 to 10, with higher scores indicating more severe nasal symptoms. The CCCRC test kit comprises odor detection and identification tests.11 The detection threshold is measured using nine serial dilutions of butanol in nanopuredeionized water. The threshold is defined as the dilution at which the butanol bottle is correctly identified in four consecutive trials. To assess olfactory function, the CCSIT—a widely used test of odor identification involving a scratch-and-sniff test of 12 microencapsulated odorants with a forced choice of four alternatives per item—was administrated to all subjects.12 Baseline VAS, CCCRC, and CCSIT scores were obtained at a preoperative visit, and follow-up scores were obtained 6 months postoperatively. Approval for the review of medical records of patients who underwent EETSA was provided by the institutional review
Kim et al.: Olfactory Changes After Binostril Four-Hand Approach
2471
Fig. 1. Comparison of preoperative and postoperative olfactory function using the VAS, CCCRC, and CCSIT. Baseline scores of each were obtained at a preoperative visit, and follow-up scores were obtained 6 months postoperatively. Olfactory functions showed significant worsening postoperatively (*). pre 5 preoperative; post 5 6 months postoperative. board of our university hospital. Student’s paired t tests were used to compare preoperative and postoperative symptoms and olfactory test scores (PASW Statistics 18; SPSS Inc., Chicago, IL). A P value of 31 years of age. Furthermore, few elderly people recognize their preoperative olfactory disturbance because they fail to notice the gradual decline with age. This indicates that the decreased regenerative ability of the olfactory neuroepithelium in elderly patients who have undergone EETSA may affect the postoperative restoration of olfactory function. Our study has advantages. We analyzed the results of EETSA performed by a single surgeon to avoid interoperator differences. In particular, because two surgical approaches to the sellar floor have been developed to achieve better exposure of the surgical field and low nasal morbidy by ourselves, we could more accurately evaluate the surgical results of the patients who underwent EETSA. Our study may also have some inherent weaknesses. One limitation of our study design is the relatively short follow-up period and another is the retrospective review. We used only one time point (6 months postoperatively) for follow-up. Thus, we could not investigate changes in nasal symptoms after 6 months. Long-term follow-up is among our future goals for the evaluation of postoperative changes in olfaction. This series was not a randomized controlled trial, which would be more powerful than a retrospective study. Laryngoscope 124: November 2014
2474
However, we believe that our series would overcome the weaknesses of retrospective review because of the relatively large number of patients. We attempted to evaluate subjective olfactory changes in patients who underwent EETSA before and after surgery. Before surgery is performed, patients scheduled for EETSA should understand that postoperative olfactory impairment are possible. Therefore, we suggest that rhinologists consider postoperative nasal symptoms and perform a proper preoperative examination, especially with regard to the olfactory function, and inform patients scheduled for EETSA of potential postoperative changes. Rhinologic surgeons should pay careful attention to meticulous manipulation of the intranasal structures, including the olfactory neuroepithelium. We must develop proper surgical techniques for the prevention of olfactory changes. Development of a technique to decrease injury to the posterior–superior area of the nasal septum and superior turbinate in which the olfactory epithelium is distributed prevents olfactory dysfunction. This could preserve quality of life.
CONCLUSION Patients undergoing EETSA experience some sinonasal morbidity in the postoperative period. It is suggested that the surgical EETSA technique might contribute to olfactory function. In addition, age may affect olfaction in EETSA. Patients scheduled for EETSA must be informed that their olfaction may be changed. In addition, rhinologic surgeons must pay close attention when manipulating the mucosa containing the olfactory neuroepithelium. We will make an effort to elucidate the cause of olfactory changes in patients undergoing EETSA.
Acknowledgment This research was supported in 2013 by Seoul St. Mary’s Hospital Clinical Medicine Research Program through the Catholic University of Korea.
BIBLIOGRAPHY 1. Rosegay H. Cushing’s legacy to transsphenoidal surgery. J Neurosurg 1981;54:448–454. 2. Adams CBT, Burke CW. Current modes of treatment of pituitary tumors. Br J Neurosurg 1993;7:123–128. 3. Rotenberg B, Tam S, Ryu WH, Duggal N. Microscopic versus endoscopic pituitary surgery: a systematic review. Laryngoscope 2010;120:1292– 1297. 4. Brent A., Charles S. Minimally invasive pituitary surgery. Laryngoscope 2008;118:1842–1855. 5. Tam S, Duggal N, Rotenberg BW. Olfactory outcomes following endoscopic pituitary surgery with or without septal flap reconstruction: a randomized controlled trial. Int Forum Allergy Rhinol 2013;3:62–65. 6. Alobid I, Ensenat J, Marino-Sanchez F, et al Impairment of olfaction and mucociliary clearance after expanded endonasal approach using vascularized septal flap reconstruction for skull base tumors. Neurosurgery 2013;72:540–546. 7. Kim BY, Son HL, Kang SG, et al. Postoperative nasal symptoms associated with an endoscopic endonasal trassphenoidal approach. Eur Arch Otorhinolaryngol 2013;270:1355–1359. 8. Kim BY, Shin JH, Kang SG, et al. Bilateral modified nasoseptal “rescue” flaps in the endoscopic endonasal transsphenoidal approach. Laryngoscope 2013;123:2605–2609. 9. Shin JH, Kang SG, Kim SW, et al. Bilateral nasoseptal flaps for endoscopic endonasal transsphenoidal approach. J Craniofac Surg 2013;24:1569–1572. 10. Cross DJ, Flexman JA, Anzai Y, et al. Age-related decrease in axonal transport measured by MR imaging in vivo. Neuroimage 2008:1;39:915– 926.
Kim et al.: Olfactory Changes After Binostril Four-Hand Approach
11. Kobayashi M, Reiter ER, DiNardo LJ, Costanzo RM. A new clinical olfactory function test: cross-cultural influence. Arch Otolaryngol Head Neck Surg 2007;133:331–336. 12. Doty RL, Marcus A, Lee WW. Development of the 12-item Cross-Cultural Smell Identification Test (CC-SIT). Laryngoscope 1996;106(pt 1):353– 356. 13. Johannes Lang. Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses. Leipzig, Germany: Georg Thieme Verlag; 1989. 14. Rotenberg BW, Saunders S, Duggal N. Olfactory outcomes after endoscopic transsphenoidal pituitary surgery. Laryngoscope 2011;121:1611–1613.
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15. Balaker AE, Bergsneider M, Martin NA, Wang MB. Evolution of sinonasal symptoms following endoscopic anterior skull base surgery. Skull Base 2010;20:245–251. 16. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006;116:1882–1886. 17. Eccles R. Nasal airflow in health and disease. Acta Otolaryngol 2000;120: 580–95. 18. Seiberling KA, Conley DB. Aging and olfactory and taste function. Otolaryngol Clin N Am 2004;37:1209–1228.
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Rhinological and Otological Society, Inc.
Olfactory Changes After Endoscopic Endonasal Transsphenoidal Approach for Skull Base Tumors Boo-Young Kim, MD; Seok-Gu Kang, MD, PhD; Sung W. Kim, MD, PhD; Yong K. Hong, MD, PhD; Sin-Soo Jeun, MD, PhD; Soo W. Kim, MD, PhD; Hyun B. Kim, MD; Min Kim, MD; Jae H. Maeng, MD; Dong C. Lee, MD; Jin H. Cho, MD, PhD; Yong J. Park, MD, PhD Objectives/Hypothesis: The increased number of endoscopic endonasal transsphenoidal approaches (EETSA) has been associated with sinonasal complications such as olfactory dysfunction. Current studies have compared preoperative and postoperative olfactory function according to surgical type and age. Study Design: Retrospective review of medical records at a tertiary referral center. Methods: Patients were divided into two groups according to surgical type and into four groups according to age. The two surgical groups were defined based on the bilateral nasoseptal flap technique (group A: right conventional nasoseptal flap and left modified nasoseptal rescure flap; group B: bilateral modified nasoseptal rescue flap). The four age groups were 30, 31–45, 46–60, and 61 years. Patients underwent preoperative olfactory function evaluation using a visual analogue scale (VAS), the Connecticut Chemosensory Clinical Research Center Test (CCCRC), and the Cross-Cultural Smell Identification Test (CCSIT). Repeat testing was performed 6-months postoperatively. Results: A total of 226 patients who underwent binostril four-hand EETSA were included in this study. In both groups A and B, the olfactory function was significantly decreased according to CCCRC and CCSIT scores (P < 0.05). The VAS scores were significantly decreased in both groups (P < 0.05). The symptom scores and olfactory test results were significantly changed in >30-year-old patients who had undergone EETSA. Conclusion: EETSA might contribute to olfactory dysfunction independent of surgery type. In addition, age may affect the restoration of olfaction after EETSA. Patients who plan to undergo EETSA must be informed that their olfaction may be impaired. Key Words: Nasal symptom, endoscope, transsphenoidal approach, skull base tumor, olfactory change, age. Level of Evidence: 4. Laryngoscope, 124:2470–2475, 2014
INTRODUCTION The transsphenoidal route for anterocentral skull base surgery1 has been the standard surgical treatment for sellar tumors,2 and the use of the binostril four-hand endoscopic endonasal transsphenoidal approach (EETSA) for skull-base lesions has increased.3 Although outcomes are comparable with those of traditional transsphenoidal approaches, EETSA is associated with relatively low complication rate.4 However, the increase in the number of EETSA procedures has been associated with several sinonasal complications such as olfactory
From the Department of Otolaryngology–Head and Neck Surgery (B-Y.K., SUNG W.K., SOO W. K., H.B.K., M.K., M.J.H., D.C.L., J.H.C., Y.J.P.); the Department of Neurosurgery (S-G.K., Y.K.H., S-S.J.); the Minimal Access and Robotic Surgery Center, Seoul St. Mary’s Hospital (SUNG W.K., S-S.J.); and the Department of Biomedical Science (SUNG W.K., S-S.J.), The Catholic University of Korea, College of Medicine, Seoul, Korea Editor’s Note: This Manuscript was accepted for publication March 5, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Sung Won Kim, MD, PhD, Department of Otolaryngology–Head and Neck Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul, 137–701, Korea. E-mail: [email protected] DOI: 10.1002/lary.24674
Laryngoscope 124: November 2014
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dysfunction because of the resection of anatomical structures known to contain olfactory neuroepithelium.5,6 In our previous studies, the symptom scores of olfactory change increased significantly after EETSA (P < 0.05).7 However, an subjective diminution of olfactory function undergoing EETSA has been poorly documented in previous literature involving small populations. Therefore, we investigated the distinction between preoperative and postoperative olfactory function using a visual analogue scale (VAS), the Connecticut Chemosensory Clinical Research Center test (CCCRC), and the Cross-Cultural Smell Identification Test (CCSIT). The present study was performed to compare preoperative and postoperative olfactory function according to surgery type (representative of the extent of olfactory mucosal damage) and patient age to estimate the regenerative ability of the olfactory neuroepithelium.
MATERIALS AND METHODS Between February 2009 and October 2012, a total of 285 patients with anterocentral skull-base tumors including pituitary adenoma underwent operations via EETSA at Seoul St. Mary’s Hospital, The Catholic University of Korea. Of these, 226 were completely followed up by olfactory function evaluation for at least 6 months postoperatively.
Kim et al.: Olfactory Changes After Binostril Four-Hand Approach
All patients underwent nasal endoscopic examination and paranasal sinus computed tomography (CT), and those who showed abnormalities in the sinonasal space were excluded. Patients with previous nasal or sinus surgery, history of asthma, or sinonasal diseases were excluded. We also excluded the pateints with a history of olfactory disturbance before EETSA. Patients were divided into two groups according to the surgical approach: group A, right conventional nasoseptal flap and left modified nasoseptal rescue flap; and group B, bilateral modified nasoseptal rescue flaps.8,9 Patients were also divided to four groups according to age: 30 years (n 5 42), 31–45 years (n 5 60), 46–60 years (n 5 71), and 61 years (n 5 53).10 Patients underwent preoperative olfactory function evaluation using VAS, CCCRC, and CCSIT to address olfactory difficulty. Repeat testing was performed 6 months postoperatively.
Surgical Technique Group A: Right conventional nasoseptal flap and left modified nasoseptal rescue flap9. The procedures to harvest bilateral nasoseptal flap were as follows. First, the flap was designed on the right side of the nasal septum. With monopolar sharp electrocautery, one incision was made from the inferior border of the sphenoidal sinus ostium following the sagittal plane of the septum, 1 cm below the most superior aspect of the septum; and a parallel incision was made over the vomer, palatine crest, and maxillary crest. These incisions were joined anteriorly by a vertical incision made with a no. 15 blade scalpel in the area opposite the caudal end of the inferior turbinate. Mucoperichondrial and mucoperiosteal flaps were developed from the right side of the bony nasal septum with Cottle, Freer, and hockey-stick-shaped elevators (Karl Storz GmbH & Co. KG, Tuttlingen, Germany). At the anterior face of the sphenoid, the flap was elevated more carefully to preserve a posterolateral neurovascular pedicle. The right ostium of the sphenoidal sinus was widened superiorly and inferiorly with a rongeur. After elevating the right pedicled septal mucosal flap, we performed a posterior septectomy that included a portion of the perpendicular plate of the ethmoid bone (PPE), the vomer, and the anterior wall of the sphenoidal sinus. During that surgical procedure, we tried to remove bony material as an en bloc for use in the reconstruction of the sellar floor. After the posterior septectomy, the sellar floor was visible. The left modified nasoseptal rrescue flap was designed along the line of removed septal bone. After harvesting, both nasoseptal flaps were displaced into the nasopharynx during the extirpative phase of the surgery to avoid any injury affecting the potential use of those flaps. Mucosal bleeding was controlled with 1:100,000 epinephrine-soaked cotton pledgets and Surgicel (Ethicon; Johnson & Johnson, Somerville, NJ), and major bleeding was controlled with suction electrocautery and a collagen hemostatic agent. We reconstructed the surgical defect using a multilayer technique after removal of tumor. First, the vomer or the PPE was placed in the bony defect as a rigid buttress in cases with CSF leakage. The reflected sphenoidal sinus mucosa was repositioned to cover the operative site. When CSF leakage was suspected after inserting a bony buttress graft with the Valsalva maneuver (anesthetic bagging), we used the right nasoseptal flap to cover the bone graft. The right nasoseptal flap was rotated to cover the defect and overlap the bony edge of the surgical defect. To facilitate attachment of the flap and prevent mucocele formation, the surrounding mucosa was stripped before flap application. The left modified nasoseptal rescue flap was used when excessive sphenoidal mucosa was removed. The
Laryngoscope 124: November 2014
denuded sphenoidal sinus was covered with the left modified nasoseptal rescue flap. Unused flaps were repositioned in the original sites, and unused septal bone resected en bloc was inserted between the bilateral nasoseptal flaps. The right flap was repositioned and the incisions were closed with 5-0 polydioxanone (PDS) sutures. The left flap was repositioned without suturing. Group B: Bilateral modified nasoseptal rescue flaps8. The procedure to harvest the bilateral modified nasoseptal rescue flaps was as follows. First, the flap was designed on the right side of the nasal septum. With monopolar sharp electrocautery, a curvilinear incision was made from the inferior border of the sphenoidal sinus ostium following the sagittal plane of the septum. This incision was made anteriorly toward the level of one-half to one-third the height of the middle turbinate over the vomer to preserve the nasoseptal pedicle. This incision was the main distinction between a conventional nasoseptal flap and a modified nasoseptal rescue flap. A mucoperiosteal flap was developed from the right side of the bony nasal septum with Cottle and hockey stick elevators. At the anterior face of the sphenoid, the flap was elevated more carefully to preserve the posterolateral neurovascular pedicle. The right ostium of the sphenoidal sinus was widened superiorly and inferiorly with a rongeur. After elevating the right modified nasoseptal rescue flap, the posterior bony septum that included a portion of the perpendicular plate of the ethmoid bone, the vomer, and the anterior wall of the sphenoidal sinus was removed. During the surgical procedure, we tried to remove the bony material en bloc for use in the reconstruction of the sellar floor. After this procedure, we could identify the sellar floor. The left modified nasoseptal rescue flap was designed along the line of the removed septal bone. Both modified nasoseptal rescue flaps were then displaced into the nasopharynx during the extirpative phase of the surgery to avoid any injury affecting the potential use of those flaps. Simultaneous septoplasty was performed with no additional incision in patients with nasal septal deviation, which would cause narrowing of the nasal cavities to hinder manipulation of the endoscope. Mucosal bleeding was controlled with 1:100,000 epinephrinesoaked cotton pledgets and an absorbable hemostat (Surgicel, Ethicon; Johnson & Johnson, Somerville, NJ); and major bleeding was controlled with suction electrocautery and a collagen hemostatic agent. Unused modified nasoseptal rescue flaps were repositioned in the original sites, and unused septal bone resected en bloc was inserted between the bilateral modified nasoseptal rescue flaps to strengthen the repositioned bilateral modified nasoseptal rescue flaps. Both modified nasoseptal rescue flaps were repositioned without suturing. The VAS evaluated olfactory difficulty and was used to assess preoperative and postoperative subjective olfactory symptoms. It was scored from 0 to 10, with higher scores indicating more severe nasal symptoms. The CCCRC test kit comprises odor detection and identification tests.11 The detection threshold is measured using nine serial dilutions of butanol in nanopuredeionized water. The threshold is defined as the dilution at which the butanol bottle is correctly identified in four consecutive trials. To assess olfactory function, the CCSIT—a widely used test of odor identification involving a scratch-and-sniff test of 12 microencapsulated odorants with a forced choice of four alternatives per item—was administrated to all subjects.12 Baseline VAS, CCCRC, and CCSIT scores were obtained at a preoperative visit, and follow-up scores were obtained 6 months postoperatively. Approval for the review of medical records of patients who underwent EETSA was provided by the institutional review
Kim et al.: Olfactory Changes After Binostril Four-Hand Approach
2471
Fig. 1. Comparison of preoperative and postoperative olfactory function using the VAS, CCCRC, and CCSIT. Baseline scores of each were obtained at a preoperative visit, and follow-up scores were obtained 6 months postoperatively. Olfactory functions showed significant worsening postoperatively (*). pre 5 preoperative; post 5 6 months postoperative. board of our university hospital. Student’s paired t tests were used to compare preoperative and postoperative symptoms and olfactory test scores (PASW Statistics 18; SPSS Inc., Chicago, IL). A P value of 31 years of age. Furthermore, few elderly people recognize their preoperative olfactory disturbance because they fail to notice the gradual decline with age. This indicates that the decreased regenerative ability of the olfactory neuroepithelium in elderly patients who have undergone EETSA may affect the postoperative restoration of olfactory function. Our study has advantages. We analyzed the results of EETSA performed by a single surgeon to avoid interoperator differences. In particular, because two surgical approaches to the sellar floor have been developed to achieve better exposure of the surgical field and low nasal morbidy by ourselves, we could more accurately evaluate the surgical results of the patients who underwent EETSA. Our study may also have some inherent weaknesses. One limitation of our study design is the relatively short follow-up period and another is the retrospective review. We used only one time point (6 months postoperatively) for follow-up. Thus, we could not investigate changes in nasal symptoms after 6 months. Long-term follow-up is among our future goals for the evaluation of postoperative changes in olfaction. This series was not a randomized controlled trial, which would be more powerful than a retrospective study. Laryngoscope 124: November 2014
2474
However, we believe that our series would overcome the weaknesses of retrospective review because of the relatively large number of patients. We attempted to evaluate subjective olfactory changes in patients who underwent EETSA before and after surgery. Before surgery is performed, patients scheduled for EETSA should understand that postoperative olfactory impairment are possible. Therefore, we suggest that rhinologists consider postoperative nasal symptoms and perform a proper preoperative examination, especially with regard to the olfactory function, and inform patients scheduled for EETSA of potential postoperative changes. Rhinologic surgeons should pay careful attention to meticulous manipulation of the intranasal structures, including the olfactory neuroepithelium. We must develop proper surgical techniques for the prevention of olfactory changes. Development of a technique to decrease injury to the posterior–superior area of the nasal septum and superior turbinate in which the olfactory epithelium is distributed prevents olfactory dysfunction. This could preserve quality of life.
CONCLUSION Patients undergoing EETSA experience some sinonasal morbidity in the postoperative period. It is suggested that the surgical EETSA technique might contribute to olfactory function. In addition, age may affect olfaction in EETSA. Patients scheduled for EETSA must be informed that their olfaction may be changed. In addition, rhinologic surgeons must pay close attention when manipulating the mucosa containing the olfactory neuroepithelium. We will make an effort to elucidate the cause of olfactory changes in patients undergoing EETSA.
Acknowledgment This research was supported in 2013 by Seoul St. Mary’s Hospital Clinical Medicine Research Program through the Catholic University of Korea.
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