Is conchal type sphenoid sinus still a contraindication to endoscopic endonasal pituitary surgery?

OBJECTIVES The pattern of pneumatization of the sphenoid sinus significantly affects the safe access to the sella. Based on the degree of pneumatization, the sphenoid sinus can be divided in four types: conchal, presellar, sellar, and postsellar. The conchal or absence of pneumatization of the sphenoid sinus has been historically considered a relative contraindication for the transsphenoidal approach to the sella, since it usually causes this approach to be less favorable and quite difficult to perform. METHODS We report 5 cases (5 females, age range 22 -38 years) of patients with pituitary tumors (4 pituitary adenomas and 1 Ratke's cleft cyst) and whose sphenoid sinus was conchal type. RESULTS Different tools can make such an approach feasible even in cases with poorly or no pneumatized spend sinuses. All patients were operated upon with the aid of neuronavigation and low-profile high- speed endonasal microdrills. Using such tools, we were able in all cases to effectively access the sellar cavity and obtain a gross total removal of the pituitary adenoma avoiding, at the same time, misdirection of the instruments and injury to the surrounding neurovascular structures. CONCLUSIONS The availability of intraoperative navigational devices - specially using CT-based images - can be used to confirm surgical landmarks and the direction of the approach and the use of low-profile high-speed endonasal microdrills make it possible to access the sella through the sphenoid sinus safely even in such poorly pneumatized cases.