BACKGROUND AND CLINICAL SIGNIFICANCE
Over the past decade, the surgical method for removing pituitary tumors has shifted from
a microscopic resection technique performed exclusively by a neurosurgeon, to an
endoscopic resection done as a team with an otolaryngologist and neurosurgeon. This field
continues to evolve given this recent shift in treatment technique.
Nasal packing has historically been a post-operative intervention of treating the nose
employed by otolaryngologists for any nasal surgery they performed. However, with the
advent of endoscopic sinus surgery and changes in surgical technique, the use of nasal
packing has become less common. A systematic review by Quinn et. Al (2013) showed that
nasal packing caused more patient discomfort than any other post-septoplasty maneuver and
did not prevent complications of septoplasty, but could contribute to adverse events
following septoplasty. In North America, nasal packing is no longer commonly used after
septoplasty.
However, following the endoscopic resection of pituitary tumors, the practice of nasal
packing is still widely employed. The reasoning for placement of nasal packing following
surgery is not clear, just as it was not for its use following septoplasty. A thorough
search of the literature did not identify any publications providing justification for
the use of nasal packing. Published recommendations to reduce incidence of post-operative
nasal complications after transsphenoidal pituitary tumor resection include use of
specific nasal medications (intranasal corticosteroids) and regular nasal saline
irrigation (in patients without cerebrospinal fluid rhinorrhea) to clear nasal mucosal
hyperemia edema and secretions, as well as to prevent nasal synechiae and scarring, to
maintain the sinus cavity drainage, and accelerate the recovery of the physiological
function of the paranasal sinus. However, an evidence based recommendation in support or
against routine nasal packing has not been made. A review from neurosurgical literature
on perioperative management post transsphenoidal pituitary resection reports the majority
of patients do not require insertion of nasal packing at the time of surgery, some
patients (intraoperative Cerebral spinal fluid (CSF) leaks requiring sellar floor
reconstruction, Cushing's Disease, and acromegaly) may benefit from their insertion, and
if used packing is typically removed postoperative day 1.
In January 2018 an informal email survey of Canadian Otolaryngologists who routinely
perform endoscopic pituitary surgery with a neurosurgeon (total of 7 respondents out of
11 surgeons, 64% response rate) demonstrated that 5 of 7 use nasal packing following the
procedure; 2 of 7 do not. Packing is usually left in place for 48 hours when used. A
screening of institution websites (February 12, 2018) in North America where this surgery
is routinely performed found a balanced number of institutions that list the use or
non-use of nasal packing following endoscopic pituitary tumor resection (13 institutional
websites screened, 8 institutions routinely use nasal packing, 5 do not). There is
clinical equipoise related to the use of nasal packing. An objective study assessing the
utility of nasal packing following endoscopic endonasal pituitary surgery has not yet
been completed.
This study seeks to answer the question, "Is routine nasal packing following endoscopic
pituitary tumor surgery a necessary treatment?". The results of this trial have the
potential to standardize practice patterns in Canada and internationally, and will inform
evidence based practice while directly impacting the quality of care delivered to
patients undergoing pituitary tumor resection.
HYPOTHESIS
Nasal packing following routine endoscopic pituitary tumor surgery is an unnecessary
intervention that may cause patients unjustified post-operative discomfort, negatively
affect their quality of life, and unnecessarily increase associated cost of care.
