Nasal Packing Following Endoscopic Endonasal Pituitary Resection
Nasal Packing Following Endoscopic Endonasal Pituitary Resection
There is considerable controversy about the use of nasal packing following endoscopic
 endonasal resection of pituitary tumors as a necessary treatment amongst Rhinology-Skull Base
 Surgeons. The justification for the routine use of nasal packing following pituitary surgery
 is not clear as this practice is not used for equally extensive sinus surgery. Further
 scientific evidence supporting this practice is lacking, and a recent survey of Canadian
 surgeons performing this surgery demonstrates clear division in practice for the routine use
 of nasal packing. Nasal packing causes patients significant discomfort requiring medication,
 and the use of packing adds direct and unintended hospitalization and health system costs for
 every case for which it is used. The benefits, short-comings, and associated costs of nasal
 packing following endoscopic endonasal transsphenoidal pituitary resection have not been
 studied.

 OBJECTIVE: To determine if nasal packing following endoscopic endonasal pituitary tumor
 surgery is a necessary treatment. The principal research questions for this study, our
 internal pilot of the RCT, pertain to feasibility of enrolment of patients undergoing
 endoscopic endonasal transsphenoidal pituitary tumor surgery using the full RCT protocol of
 nasal packing versus no nasal packing. The pilot will address feasibility of site-specific
 enrolment and feasibility of institutional ethics approval and protocol administration.
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.
Inclusion Criteria:

 -  18 years of age or older

 -  undergoing endoscopic endonasal transsphenoidal approach to pituitary resection for
 pituitary tumors of any pathology for the first time

 Exclusion Criteria:

 -  patients who do not have a working understanding of English

 -  patients with known allergy to Merocel nasal packing