The whole procedure commonly involves one nostril, through which the endoscope (fixed to its holder) plus one or two instruments are inserted. Two important variants determine a deviation from the standard procedure:
The nasal and paranasal anatomy can be distorted by (1)hypertrophy of the turbinates on both sides from various nasal pathologies, (2) by the presence of a concha bullosa of the middle turbinate, and (3) by other anatomic variations that, narrowing the nostrils, can cause difficulties in reaching and working safely in
The surgical procedure is not strictly median because of the nasal septum and the prominence of the nasal turbinates (especially the middle and the superior) that can prevent the endoscope and other instruments from being angled sufficiently laterally to the limit of the lesion. When access to the sellar lesion extends beyond the angle of maneuver of the instruments, even if the endoscope allows the surgeon to see the lesion, it may not be possible to remove it.
The endoscopic endonasal procedure can be adapted to different patterns of extension of the sellar lesion, allowing adequate surgical access. These modifications include hemisphenoidotomy, the enlarged approach with the removal of superior and/or supreme turbinate, and the bilateral nostril approach.
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