Superior turbinectomy: role for a two-surgeon technique in endoscopic endonasal transsphenoidal surgery--technical note

Abstract

We describe a practical technique of superior turbinectomy followed by posterior ethmoidectomy as a less invasive procedure for two-surgeon technique on endoscopic endonasal transsphenoidal surgery. After identification of the superior turbinate and the sphenoid ostium, the inferior third portion of the superior turbinate was coagulated and resected. This partial superior turbinectomy procedure exposed the posterior ethmoidal sinus. Resection of the bony walls between the sphenoid and posterior ethmoid sinuses provided more lateral and superior exposure of the sphenoid sinus. This technique was performed in 56 patients with midline skull base lesions, including 49 pituitary adenomas and 7 other lesions. Meticulous manipulation of instruments was performed in all cases without surgical complications such as permanent hyposmia/anosmia or nasal bleeding. Our findings suggested that the partial superior turbinectomy followed by retrograde posterior ethmoidectomy is a simple and safe technique providing a sufficient surgical corridor for two-surgeon technique to approaching midline skull base regions, mainly involving pituitary adenomas.

Fig. 1.

Bone window computed tomography images of patient with macroadenoma. An axial (A) and coronal (B) section clearly revealed the relationship of the landmarks of sinonasal anatomy. Arrow: ostium of the sphenoid sinus, arrowhead: superior turbinate asterisk: sphenoid sinus, white dot: posterior ethmoid cell.

Fig. 2.

Intraoperative endoscopic view of left sphenoethmoidal recess. Sphenoid ostium (SphO) was located medial to the superior turbinate (ST). Asterisk: ostium of the posterior ethmoid sinus, MT: middle turbinate, NS: nasal septum.

Fig. 3.

Magnified endoscopic view of left sphenoid ostium after resection of superior turbinate. The bony wall between posterior ethmoidal cell and sphenoid sinus was identified. Asterisk: stump of superior turbinate after resection, MT: middle turbinate, NS: nasal septum, SphO: ostium of the sphenoid sinus.

Fig. 4.

Final endoscopic view of posterior and lateral walls of the sphenoid sinus after wide sphenoidotomy. Tip of an endoscope was set in front of the right sphenoethmoidal recess. The floor of the sella turcica has been removed. The planum sphenoidale (PSph), optic canal or optic nerve (ON), carotid prominence or internal carotid artery (ICA), and lateral opticocarotid recess (LOCR) are visible bilaterally. Asterisk: suction tube, C: clivus, DM: dura mater, MT: middle turbinate, NS: nasal septum.

Fig. 5.

Postoperative three-dimensional (3D) computed tomography (CT) reconstruction bone image of sinonasal cavities in a patient who underwent partial superior turbinectomy and posterior ethmoidectomy on the right side. (A). The viewing direction was shown by a large arrow (B). The 3D image of the posterior ethmoidal area (light gray) was superimposed on that of the posterior sphenoidal wall (dark gray) in an anteroposterior direction. These images were obtained separately from multidetector CT volumetric data of region a (the posterior ethmoidal area) and region b (the posterior sphenoidal wall) (B). The areas encircled by dotted lines showed the most posterior ethmoid cells and their posterior walls were deleted deliberately on image reconstruction (A). The lateral structures in the sphenoid sinus including the opticocarotid recesses were difficult to be observed in a direction parallel with the nasal septum, and the superior turbinectomy with posterior ethmoidectomy provided a further superolateal view (small arrows) and an additional space for driving an endoscope. arrowhead: left superior turbinate, asterisk: lateral opticocarotid recess, C: clivus, CP: carotid prominence, S: sellar floor drilled away in surgery.