Mononostril versus binostril versus one and a half Nostril Endoscopic Trans sphenoidal approach for pituitary adenoma

Background and Aim: Over the past 2 decades, endoscopy has become an integral part of the surgical repertoire for pituitary procedures and over the past several decades, the endoscopic endonasal trans sphenoidal approach (EETA) has gradually become an accepted option for pituitary tumors with intra-,supra-,and para-sellar location and extension, because of its minimal invasiveness and high efficiency. Over the past several decades EETA offers improved illumination and superior panoramic visualization of the sella and the surrounding structures. Compared with traditional sub labial or trans septal microscopic approach, EETA offers minimal invasiveness, fewer complications, and overall improved outcomes. However, some EETA operations are performed through one nostril (mononostril endoscopic Trans sphenoidal approach [META]), while other EETA operations are performed through both nostrils (binostril endoscopic Tranchr(chr('39')39chr('39'))s sphenoidal approach [BETA]) and recently through one and a half nostril approach [OETA]. Both of these three approaches have some pros and cons.The real aim of this study is to compare between 3different EETAs from pros and cons viewpoint of these three approaches and some comparison between traditional microsurgery (microscopic trans sphenoidal approach) and transcranial approach and EETA in pituitary adenoma. Methods: To provide up-to-date information on these three approaches, we concisely reviewed these three approaches and their pros and cons. Using the keywords, neuroendoscopy, META ,OETA , BETA ,pituitary adenoma,EETA,endoscopy, pituitary surgery, trans sphenoidal approach, binostril, mononostril, one and a half nostril, transcranial approach for pituitary adenoma, microscopic trans sphenoidal approach all the relevant articles were retrieved from Google Scholar,PubMed,and Medline reviewed, and critically analyzed. Results: Because of maneuverability of instruments and a wider view in the sphenoid sinus, the binostril technique is superior for resection of large tumors with parasellar and suprasellar extension and tumors requiring extended approaches. The mononostril technique is preferable for tumors with limited extension in the intra- and suprasellar area. Limitations to the mononostril approach may be as following: a crowded narrow nasal cavity, a harder tumor with invasive appearance or significant suprasellar extension, and lesions other than pituitary adenomas. The mononostril surgery may then be simply turned into a binostril, wider and more dynamic approach to allow for better dissection of such larger, harder, and more extensive tumors. However, we believe that these limitations resolve with changing in the lens of endoscope and some maneuver in creation of visual field in nasal cavity and transsphenoidal rout. The one-and-a-half nostril endoscopic trans sphenoidal approach is a simple and reliable technique. It provides not only a sufficient surgical corridor for a 2-surgeon/4 or 3-hands technique, but also ensures minimal invasion of the nasal canal.Its clinical results with respect to surgical outcome, maneuverability of instruments, postoperative morbidity, and postoperative quality of life support the theory that this is a highly efficient technique. Conclusions: Based on the results of this study for selecting suitable EETA as META or BETA or OETA, the size and consistency of tumor,general versus invasive pituitary adenoma, and the extent of parasellar and suprasellar extension are important and transcranial approach is effective when resection becomes necessary for a portion or all of a pituitary macroadenoma that is judged to be inaccessible from the transsphenoidal route and looks like microscopic transsphenoidal approach is suitable for pediatrics pituitary adenoma, but for more reliable conclusion further studies are needed to prove this more conclusively.