Prevalence and Clinical Management of Radiographic Sinus Disease on Preoperative CT Imaging in the Endoscopic Endonasal Skull Base Surgery Population

Introduction: Endoscopic endonasal skull base surgery (EESBS) provides a safe and minimally invasive approach to treat a variety of benign and malignant skull base lesions. Preoperative imaging is routinely obtained and is essential for evaluation of skull base anatomy, surgical planning, and intraoperative image guided neuronavigation. Often, sinonasal disease is concurrently noted and can potentially alter the plan of care. The significance of concomitant sinonasal pathology on imaging in patients with skull base lesions undergoing endoscopic endonasal approaches and its effect on preoperative and/or intraoperative management is not well described in the literature. The purpose of this study was to identify the prevalence and clinical implications of radiographic sinus disease noted on preoperative imaging in patients undergoing EESBS.

Methods: A retrospective chart review was performed of all patients who underwent EESBS from January 1, 2016, to June 30, 2017. Patients who underwent EESBS for treatment of meningoencephaloceles, sinonasal tumors with intracranial extension, or intracranial lesions with significant intranasal spread were excluded, as this would falsely alter the radiologic appearance of the paranasal sinuses. Preoperative computed tomography (CT) scans were reviewed for each patient and Lund-Mackay scores were obtained. In addition, nasal endoscopy findings at preoperative otolaryngology clinic visits were analyzed. Any preoperative treatment based on these findings and changes in intraoperative management were recorded.

Results: A total of 114 patients who underwent EESBS for management of sellar and parasellar lesions met our inclusion criteria. Age at the time of surgery was 51 ± 15.6 years and 44.7% (51/114) of patients were male. Average Lund-Mackay score was 1.95 ± 2.5 (range: 0–12). A total of 74 patients (64.9%) had evidence of radiographic sinus disease (Lund-Mackay score > 0), of which 17 patients (14.9%) had presence of sphenoid sinus disease. There were 3 (2.6%) patients with a history of chronic rhinosinusitis. Overall, 6 patients (5.3%) were treated preoperatively with at least 1 week of antibiotics either due to findings on preoperative CT scan suggestive of acute sinusitis with presence of associated symptoms (2 patients) or due to evidence of infection on preoperative nasal endoscopy (4 patients). Of note, all 6 patients pretreated with antibiotics had evidence of radiographic disease with average Lund-Mackay score of 3.67 and were evaluated and treated within 1 to 2 weeks prior to surgery. No evidence of infection was noted intraoperatively and surgery was not postponed secondary to infection in any of these patients.

Conclusion: Detailed review of preoperative imaging in patients undergoing EESBS can help identify concurrent sinonasal disease, which can alter preoperative management of these patients. Presence of significant radiographic disease should trigger an endoscopic evaluation within 2 weeks of surgery in an effort to recognize and adequately treat any sinusitis prior to EESBS with appropriate antibiotic therapy. This approach can mitigate the risk of intracranial infection and potential cancellation of surgery.