Impact of middle turbinate resection on skull base exposure in endoscopic transsphenoidal surgery for pituitary adenoma

Abstract

Background: Endoscopic transsphenoidal surgery (ETS) has become the preferred minimally invasive approach for resection of pituitary adenomas. During this procedure, the middle turbinate often lies within the surgical corridor, prompting surgeons to either preserve or partially resect it to optimize exposure. Whether middle turbinate resection (MTR) confers a meaningful improvement in visualization of key skull base structures without increasing postoperative nasal morbidity remains unresolved. This study aimed to evaluate the impact of middle turbinate management on surgical exposure of skull base structures during endoscopic transsphenoidal surgery for pituitary adenoma. Methods: A prospective observational study was conducted at Ghazi Al-Hariri Hospital for Surgical Specialties, Baghdad, between January 2020 and June 2021. One hundred patients with confirmed pituitary adenomas were included and divided into two groups: Group A (n = 92), in whom the middle turbinate was preserved; and Group B (n = 8), in whom partial middle turbinate trimming was performed. Intraoperative exposure of six anatomical targets planum sphenoidale, sella turcica, clivus, optic nerve prominence, cavernous carotid artery prominence, and carotid-optic recess was systematically assessed. Postoperative epistaxis was recorded. Statistical analysis employed the chi-square test and Fisher's exact test (p< 0.05 for significance). Results: Adequate visualization of all assessed skull base structures was achieved in both groups, with no statistically significant between-group differences (P> 0.05 for all anatomical targets). Postoperative epistaxis occurred in one patient (12.5%) in the trimming group and in none in the preservation group (P = 0.001), indicating a significantly higher complication rate associated with turbinate resection. Conclusion: Routine middle turbinate resection does not improve intraoperative visualization of skull base structures during standard endoscopic transsphenoidal surgery for pituitary adenoma. Turbinate preservation provides equivalent surgical access while reducing the risk of postoperative nasal complications. Selective resection should be reserved for cases with unfavorable nasal anatomy or inadequate access despite turbinate lateralization.