Endoscopic endonasal transsphenoidal pituitary surgery (EETPS) has become the preferred surgical approach for the management of pituitary adenomas and other sellar and parasellar lesions [1-3]. This shift reflects the minimally invasive nature of the technique, superior illumination, panoramic visualization and enhanced access to the sellar region and skull base compared with traditional microscopic approaches [1,2]. From an otolaryngologic perspective, the endoscopic endonasal corridor offers unique advantages, as it exploits natural nasal pathways and enables precise identification and preservation of sinonasal and skull base anatomy, which are critical for both surgical exposure and reconstruction [3,4]. The role of otolaryngologists in EETPS has expanded substantially, evolving from providing surgical access to assuming a central role in skull base and sellar reconstruction [4,5]. Despite technical advances and improved visualization, postoperative cerebrospinal fluid (CSF) rhinorrhea remains one of the most frequent and clinically significant complications following EETPS [6]. The reported incidence of postoperative CSF leakage varies widely in the literature, influenced by tumor size, suprasellar extension, intraoperative CSF leakage and the reconstruction technique employed [6,7]. CSF rhinorrhea is associated with serious complications, including meningitis, pneumocephalus, prolonged hospitalization, need for reoperation and increased healthcare costs, highlighting the importance of effective and reliable sellar reconstruction [8,9]. Postoperative CSF leakage typically results from defects in the diaphragma sellae or arachnoid membrane, which may be present preoperatively due to tumor invasion or created intraoperatively during tumor resection [10]. Numerous studies have identified intraoperative CSF leakage as the most significant predictor of postoperative rhinorrhea, with markedly higher leak rates observed in cases where CSF escape is encountered during surgery [11,12]. As a result, meticulous reconstruction of the sellar floor has become a fundamental component of successful endoscopic pituitary surgery. A wide range of reconstructive materials and techniques has been described, including autologous tissues such as fat, fascia lata and muscle, synthetic grafts and sealants, rigid buttresses and vascularized flaps [13,14]. From the otolaryngologic standpoint, the introduction of vascularized pedicled flaps, particularly the nasoseptal flap, has represented a major advancement in endoscopic skull base reconstruction, significantly reducing postoperative CSF leak rates [15]. Multilayer reconstruction techniques have gained widespread acceptance due to their superior sealing capacity; however, routine application of complex reconstruction in all cases may lead to unnecessary morbidity in low-risk patients or insufficient closure in high-risk situations [16]. To address these challenges, standardized and graded sellar reconstruction algorithms have been developed, in which the reconstruction strategy is tailored according to intraoperative findings, particularly the presence and grade of CSF leakage and the size of the sellar defect [17]. These algorithms allow escalation from simple closure techniques in cases without CSF leakage to multilayer reconstruction with vascularized flaps and adjunctive measures, such as lumbar drainage, in high-risk cases [18]. Increasing evidence indicates that algorithm-based reconstruction reduces postoperative CSF rhinorrhea, improves clinical outcomes and enhances surgical consistency across institutions [19,20]. Nevertheless, continued evaluation from an otolaryngologic perspective is essential to validate the effectiveness, safety and reproducibility of these standardized reconstruction strategies in contemporary endoscopic pituitary surgery. The aim of this study is to assess the clinical outcomes of endoscopic sellar reconstruction after transsphenoidal pituitary surgery from an otolaryngologic perspective, with particular emphasis on evaluating the effectiveness of a standardized, graded reconstruction algorithm in minimizing postoperative cerebrospinal fluid rhinorrhea and related complications.

This hospital-based observational cross-sectional study was conducted in Baghdad, Iraq, at Imam Ali Hospital and Al‑Kindy Teaching Hospital over a period extending from 1 March 2024 to 31 May 2025. The study included 195 consecutive patients who underwent endoscopic endonasal transsphenoidal pituitary surgery (EETPS) for pituitary adenomas or other sellar lesions. Patients were recruited from the neurosurgery and otolaryngology departments, including both outpatient clinics and inpatient services, to ensure comprehensive case capture and uniform assessment. All surgical procedures were performed using a collaborative endoscopic endonasal approach involving neurosurgeons and otolaryngologists, with particular emphasis on the otolaryngologic role in nasal corridor preparation and sellar reconstruction. Preoperative evaluation included detailed clinical assessment, endocrine workup and radiological imaging using magnetic resonance imaging (MRI) of the sellar region.

Inclusion Criteria

• Adult patients aged 18 years or older

• Patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary or sellar lesions

• Availability of complete preoperative, intraoperative and postoperative clinical data

• Documented intraoperative assessment of cerebrospinal fluid (CSF) leakage

• Provision of written informed consent prior to participation

Exclusion Criteria

• Patients with incomplete surgical or postoperative records

• Revision transsphenoidal surgeries

• Presence of pre-existing sinonasal pathology requiring extensive additional procedures

• Patients with chronic systemic or neurological disorders that could confound postoperative outcomes

• Patients unwilling or unable to provide informed consent

Surgical Technique and Sellar Reconstruction

All patients underwent EETPS using a binostril endoscopic endonasal approach. Sellar reconstruction was performed according to a standardized, graded reconstruction algorithm, tailored to intraoperative findings. Reconstruction strategies were selected based on the presence and grade of intraoperative CSF leakage and the size of the sellar defect. Techniques ranged from simple sellar floor closure using absorbable materials in cases without CSF leakage to multilayer reconstruction employing autologous grafts, synthetic sealants, rigid buttresses and vascularized nasoseptal flaps in cases of high-flow CSF leakage. The otolaryngology team played a primary role in flap harvesting, positioning and sinonasal reconstruction.

Data Collection and Outcome Measures

Demographic data (age and sex), clinical characteristics, tumor features, intraoperative CSF leak status, reconstruction method and postoperative outcomes were recorded using a standardized data collection form. The primary outcome measure was the incidence of postoperative CSF rhinorrhea. Secondary outcomes included postoperative complications, need for reoperation, length of hospital stay and sinonasal morbidity.

Statistical Analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 26.0. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Comparative analyses were conducted using appropriate statistical tests based on data distribution and study objectives. A p-value < 0.05 was considered statistically significant.

Table 1 demonstrates the demographic characteristics of the study population. Males constituted 112 patients (57.44%), while females accounted for 83 patients (42.56%). The majority of patients were from urban areas (121; 62.05%) and a history of smoking was reported in 59 patients (30.26%).

Table 1: Demographic Characteristics of the Study Population

As shown in Table 2, headache was the most common presenting symptom, reported in all patients (195; 100.00%). Visual disturbances were observed in 151 patients (77.44%), while hormonal dysfunction-related symptoms were present in 126 patients (64.62%). Nasal obstruction and rhinorrhea were less frequent.

Table 2: Presenting Clinical Symptoms

Table 3 shows the duration of symptoms prior to surgical intervention. Symptoms exceeding one year were reported in 83 patients (42.56%), reflecting delayed presentation in a considerable proportion of cases.

Table 3: Duration of Symptoms

As demonstrated in Table 4, macroadenomas were the most frequently encountered tumors (118; 60.51%). Suprasellar extension was identified in 69 patients (35.38%), indicating advanced disease in a substantial subset.

Table 4: Radiological Tumor Characteristics

Table 5 shows that non-functioning pituitary adenomas constituted the majority of cases (136; 69.74%), while functioning adenomas accounted for 59 patients (30.26%).

Table 5: Type of Pituitary Adenoma

According to Table 6, intraoperative cerebrospinal fluid (CSF) leakage was encountered in 74 patients (37.95%). High-flow CSF leakage was identified in 21 patients (10.77%).

Table 6: Intraoperative CSF Leak Status

As presented in Table 7, multilayer reconstruction was the most frequently used technique (148; 75.90%), followed by simple sellar floor closure in low-risk cases.

Table 7: Sellar Reconstruction Techniques

Table 8 demonstrates a significantly higher rate of postoperative CSF rhinorrhea among patients with high-flow intraoperative CSF leakage (p = 0.001).

Table 8: Postoperative CSF Leak According to Intraoperative Leak Status

As shown in Table 9, postoperative sinonasal complications were uncommon. Epistaxis was the most frequent complication, occurring in 18 patients (9.23%).

Table 9: Postoperative Complications

Table 10 shows that postoperative CSF rhinorrhea was significantly associated with high-flow intraoperative CSF leakage, macroadenoma size and absence of vascularized flap reconstruction.

Table 10: Factors Associated with Postoperative CSF Rhinorrhea

Endoscopic endonasal transsphenoidal pituitary surgery (EETPS) is now widely adopted because it leverages the sinonasal corridor to access the sella with panoramic visualization and less brain retraction than traditional microscopic approaches, while maintaining strong tumor control outcomes [1-3]. From an otolaryngologic standpoint, however, the success of EETPS is inseparable from two reconstructive priorities: (a) achieving a watertight skull base closure to prevent postoperative CSF rhinorrhea and intracranial infection and (b) minimizing nasal morbidity (crusting, sinusitis, septal complications, smell disturbance) that can affect quality of life [4-7]. (4-7) The current results collectively support the value of a graded, algorithm-based reconstruction strategy that escalates closure according to intraoperative CSF leak risk, which aligns with contemporary evidence that tailored repair reduces leak rates while avoiding unnecessary morbidity in low-risk cases [8-12]. The predominance of males (57.44%) and the high proportion of urban residents (62.05%) are broadly consistent with many pituitary surgery cohorts where sex distribution is close to equal or mildly male-predominant, depending on referral patterns and lesion types included [2,13,14]. Smoking history (30.26%) is clinically relevant to ENT surgeons because smoking is associated with impaired mucociliary clearance, delayed mucosal healing and higher susceptibility to chronic rhinosinusitis-like symptoms, factors that may worsen postoperative nasal crusting, infection risk and patient-reported sinonasal quality-of-life (QOL) outcomes [6,15,16]. Although smoking is not a classic primary driver of CSF leak, it may indirectly contribute by increasing postoperative cough/pressure events and impairing mucosal repair; therefore, documenting and counseling smokers remains important in endonasal skull base pathways [6,15]. Headache (100%) and visual disturbance (77.44%) reflect the typical neuro-ophthalmic presentation of sellar lesions, especially macroadenomas and lesions with suprasellar extension [13,14,17]. Hormonal dysfunction symptoms (64.62%) also match the known clinical spectrum of functioning and non-functioning pituitary tumors [13,17]. The relatively lower rates of nasal obstruction (24.62%) and rhinorrhea (11.28%) are expected because preoperative sinonasal complaints are often modest unless there is tumor-related CSF leak, significant septal deviation, turbinate hypertrophy or coexisting chronic rhinosinusitis [6,5,18]. For ENT teams, these baseline symptoms are important for setting expectations: postoperative nasal symptoms may transiently increase due to mucosal trauma, packing or flap harvest, even if patients were minimally symptomatic preoperatively [6,15,18]. A substantial proportion reported symptoms >12 months (42.56%), suggesting delayed presentation. Longer symptom duration often correlates with larger tumor burden, increased likelihood of suprasellar extension/cavernous sinus involvement and more challenging resections, each of which can increase the probability of intraoperative arachnoid breach and CSF leak [14,19,20]. In practice, delayed presentation can also translate to longer operative time and more extensive nasal manipulation (binostril work, posterior septectomy), which may increase postoperative crusting and sinusitis risk [6,15,18]. Macroadenomas (60.51%) and suprasellar extension (35.38%) indicate that many cases had advanced anatomy. Multiple series have shown that larger tumors and extended approaches are associated with higher intraoperative CSF leak rates and greater reconstruction demands [13,14,19,20]. Cavernous sinus invasion (21.03%) further suggests complex dissection planes and potential exposure of high-flow CSF pathways when the diaphragm or arachnoid is compromised [19,20]. This pattern supports the rationale for using a graded reconstruction algorithm rather than a single uniform closure method [8-12]. Non-functioning adenomas (69.74%) commonly present late with mass effect rather than endocrine symptoms, which can explain the high macroadenoma rate and visual complaints [13,17,19]. From an ENT perspective, larger non-functioning lesions often require wider sellar exposure and more bony/mucosal work, increasing the importance of meticulous nasal preservation, careful flap planning and postoperative debridement strategies to reduce crusting and synechiae [6,15,18]. Intraoperative CSF leak occurred in 37.95%, with high-flow leaks in 10.77%. These figures are within ranges reported across the literature, which vary widely based on tumor size, revision surgery and surgeon experience [19-21]. Importantly, intraoperative CSF leak is consistently the strongest predictor of postoperative rhinorrhea and this is precisely why reconstruction algorithms are built around leak grading [8-12,19-21] Large contemporary series using algorithm-based closure have demonstrated very low postoperative leak rates when reconstruction escalates appropriately for low-flow versus high-flow defects and when vascularized flaps are reserved for high-risk situations [8-12]. Multilayer reconstruction was used in 75.90%, while nasoseptal flap (NSF) use was 31.79%. This distribution is conceptually aligned with modern ENT-skull base principles: use simpler closure for no/low-risk leaks and reserve vascularized flaps for high-flow leaks, large defects or extended approaches [8-12]. The introduction of the NSF (Hadad-Bassagasteguy flap) was a landmark that significantly improved reconstruction reliability for high-risk skull base defects [4]. However, NSF harvest may increase sinonasal morbidity (crusting, sinusitis, septal donor-site issues), so judicious selection is essential, especially in standard pituitary cases that do not require extended approaches (5-7,12]. Multi-center data suggest that several onlay strategies (mucosal grafts vs NSF) can have comparable effectiveness in experienced hands, while differing in operating time and morbidity profiles depending on defect characteristics [22]. Postoperative CSF rhinorrhea increased stepwise from no leak (1.65%) to low-flow (7.55%) and high-flow (28.57%). This gradient is highly consistent with the broader evidence base showing that intraoperative CSF leak magnitude is the dominant driver of postoperative failure, even when reconstruction is performed [19-21]. Algorithm studies specifically report that escalating from simple onlay/inlay techniques to multilayer repair with vascularized flap coverage for high-flow scenarios is associated with very low postoperative leak rates in high-risk groups [8-12]. The observed high-flow group leak rate underscores a practical point for ENT-neurosurgical teams: high-flow leaks may require not only multilayer closure but also careful buttressing, wide flap coverage and postoperative protocols (e.g., pressure control, selective lumbar drainage) based on institutional practice [9-11,23]. Epistaxis (9.23%) was the most frequent postoperative complication, while meningitis (2.05%) and septal perforation (1.54%) were uncommon. In endonasal skull base surgery, epistaxis can relate to sphenopalatine artery branches, septal flap harvest site bleeding or postoperative debridement trauma [6,7,24]. The low meningitis rate is reassuring and consistent with the concept that preventing postoperative CSF leak is the most effective meningitis prevention strategy [19,21]. Septal perforation, while uncommon, is a recognized donor-site or septal manipulation complication, particularly when bilateral septal mucosal integrity is compromised, supporting meticulous septal handling and donor-site reconstruction when flaps are used [5-7,15]. The significant associations of postoperative CSF rhinorrhea with high-flow intraoperative leak (p=0.001), macroadenoma (p=0.009) and absence of NSF (p=0.003) are biologically plausible and strongly supported by prior series [8-12,19-21]. For ENT surgeons, these findings reinforce three practice implications: Macroadenoma/extended anatomy should trigger early flap planning and readiness for multilayer repair [8-12,19,20]. Leak grade should dictate escalation, simple closure for no leak, inlay/onlay for low-flow and multilayer + vascularized flap for high-flow or persistent leaks [8-12]. High-risk patients benefit from strict nasal precautions, early identification of leak symptoms and structured postoperative nasal care to reduce sinonasal morbidity while protecting reconstruction. QOL tools such as SNOT-22 can help quantify sinonasal impact and guide follow-up [15,16,25].

A standardized, graded sellar reconstruction algorithm in EETPS is effective in reducing postoperative CSF rhinorrhea, particularly when reconstruction strategies are escalated in cases of high-flow intraoperative CSF leakage. From an otolaryngologic perspective, the integration of vascularized flaps and tailored reconstruction plays a crucial role in improving surgical outcomes and minimizing CSF-related complications.

Ethical Approval

The study protocol was reviewed and approved by the Institutional Ethical Committees of Imam Ali Hospital and Al-Kindy Teaching Hospital. Written informed consent was obtained from all participants prior to enrollment. All procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki and relevant institutional and national regulations.

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