Beyond the Sella: Role of Sphenoid Sinus Pneumatization and Anatomical Variations in Determining Outcomes of Endoscopic Pituitary Surgery

Abstract

Objective: To assess whether anatomical variations of the sphenoid sinus (including pneumatization type, extent, course of optic nerve, and septal morphology) have an influence on surgical outcomes of endoscopic transsphenoidal surgery (ETSS) for pituitary tumors.

Materials & Methods: A prospective cohort study was conducted at the Institute of Neurosciences, Lahore. We analyzed the details of 81 patients who underwent ETSS from June 2025 to December 2025. Sphenoid sinus pneumatization (pre-sellar, sellar, post-sellar), the degree of pneumatization (none, lateral extent, clivus extent, and lesser wing), Optic Nerve (ON) type (Type 1–4), and septum (single vs. double) were evaluated on preoperative CT FESS. T

Results: Majority of the patients were male, with a mean age of 46.8 ± 12.7 years, having a tumor exceeding 50 mm in size, in >70% cases, with larger tumor size meaning longer surgical duration, as also seen in lateral and clival extension types. Sellar pneumatization pattern was most common, but pre-Sellar and post-Sellar varieties, along with clival extent and type 3 ON, were associated with a higher incidence of intra- and post-op complications. The inter-sphenoid septum type didn’t have any impact on surgical outcomes.

Conclusion: The anatomy of the sphenoid sinus has a marked effect on safety and ease of ETSS. Preoperative high-resolution CT FESS showing the type and extent of pneumatization and optic nerve variations should be a mandatory step in risk stratification and tailored treatment to avoid neuro-vascular injuries.