Endoscopic Transsphenoidal Approach

Indications

• Indications for the transsphenoidal approach have significantly increased with the addition of the endoscope. Using a team approach with a skilled endoscopic rhinologist has rendered the endoscopic transsphenoidal approach a valid minimal-access method for exposing various midline skull base pathologies involving the planum sphenoidale, tuberculum sellae, medial cavernous sinus, pterygoid bone, and infrasellar clivus.

• The most common indication for the endoscopic transsphenoidal approach is a sellar mass. These lesions include pituitary adenomas, Rathke cleft cysts, and craniopharyngiomas. Although microadenomas and small macroadenomas do not require extended approaches, lesions with suprasellar, cavernous sinus, and clival extension can be resected with the extended endoscopic transsphenoidal approaches.

• Extradural and intradural chordomas can be resected using an endoscopic transsphenoidal approach with transclival extension.

• Meningiomas of the planum sphenoidale, meningiomas of the tuberculum sellae, and some small olfactory groove meningiomas are amenable to endoscopic, endonasal resection.

• Juvenile nasal angiofibromas arising from the pterygopalatine fossa can be removed through an endoscopic endonasal approach, even with extension into the infratemporal fossa and Meckel cave.

• Malignant tumors such as esthesioneuroblastoma, squamous cell carcinoma, and adenocarcinoma can be resected through an endoscopic transsphenoidal approach if the surgeon is confident that negative margins can be achieved.

• Encephaloceles, meningoencephaloceles, and other midline skull base defects prone to cerebrospinal fluid (CSF) leakage can be repaired through endonasal endoscopic approaches, avoiding a craniotomy.

• Large tumors that cannot be completely removed with an endoscope are not always contraindications to this approach. Depending on the age of the patient and the surgical goals, an endoscopic approach may augment a secondary cranial approach with internal decompression or a staged resection.