Combined Endonasal and Transseptal Approach to Achieve Binostril Access in Endoscopic Skull Base Approaches to Minimize Nasal Morbidity: A Technical Note

BACKGROUND: Feasibility and safety of endoscopic endonasal approaches have become well established, and focus has now shifted to minimizing nasal morbidity. To this end, several modifications in the nasal stage have been described that focus primarily on preservation of nasal mucosa on right side of the nasal cavity. However, nasal mucosal preservation on the left side of the nasal cavity has largely been ignored. This technical note describes a modified technique that can eliminate mucosal damage in the left nasal cavity. METHODS: A transseptal approach is used on the left, and an endonasal approach is used on the right side. A hemitransfixion incision is used to raise the left submucosal tunnel. The mucosa of the tunnel lies laterally in apposition with the lateral nasal wall, thereby protecting it from injury by repeated passage of instruments. When the tunnel mucosa is pushed back medially, the left nasal cavity appears absolutely normal without any evidence of mucosal damage. RESULTS: Combined endonasal and transseptal technique for the nasal stage was performed in 51 patients with sellar/suprasellar lesions. Nonfunctional pituitary adenomas were the most common pathology (macroadenomas: n = 14; giant adenomas: n = 10) followed by functional adenomas (acromegaly: n = 10; prolactinomas: n = 3; Cushing disease: n = 1), craniopharyngiomas (n n = 6), clival tumors (n n = 5), and tuberculum sellae meningiomas (n n = 2). CONCLUSIONS: A combination of endonasal and transseptal approaches uses the advantages of both endoscopic and microscopic approaches sans the disadvantage of restricted space seen in microscopic approaches. It makes the binostril approach least disruptive to the left nasal mucosa and thus can reduce overall morbidity of endoscopic endonasal approaches.