Iatrogenic Mucosal Injury during Endoscopic Endonasal Skull Base Surgery

Background: The endoscopic endonasal approach provides a natural corridor to numerous skull base lesions. However, the compromise for this direct access is a transient and possibly long-standing increase in nasal morbidity. While this is an accepted risk for this surgery, factors including number of passes into the nostril, surgical experience, type of instrumentation, and endoscopic guidance during insertion of the instrument may modify iatrogenic nasal mucosal injury and have not been studied.

Objective: To identify factors contributing to mucosal injury during endoscopic endonasal surgery.

Methods: A prospective observational trial examined the number of passes into each nostril of dissecting instruments, high speed drills and the endoscope during endoscopic endonasal skull base surgery. The surgical experience of the surgeon, divided into attending and trainee (fellow or resident), was also noted with each pass of the instrument. The principal outcome measure was the degree of mucosal injury and was categorized as abrasion, laceration and avulsion. In each nostril, three anatomical sites (nasal septum, inferior turbinate and middle turbinate, if preserved) were inspected at the end of the surgical procedure. Still images of each nostril were reviewed by a blinded reviewer.

Results: The number of instrument passes per minute did not differ between attending and trainee surgeons. However, endoscopic guidance and a decreased number of passes with non-powered instruments were associated with decreased mucosal injury. A trend toward decreased mucosal injury with increased surgical experience was observed.

Conclusion: Iatrogenic mucosal injury during endoscopic endonasal surgery remains a source of additional nasal morbidity. Innovative solutions to minimize intraoperative mucosal trauma should be considered to prevent unnecessary morbidity.