Tension pneumosella following transsphenoidal surgery: A systematic review

Endoscopic endonasal transsphenoidal surgery (EETS) is a common first-line approach for resection of sellar lesions such as pituitary adenomas. While these procedures are largely successful, rare or unexpected complications can occur. One such complication is tension pneumosella (TP). Here, we conducted a systematic review of the literature to provide recommendations on how best to identify, manage and prevent TP post-EETS.

A systematic review was conducted using PubMed, Google Scholar, Embase, Cochrane and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles discussing TP following EETS.

Eleven articles published between 1995 and 2023 detailing twelve (12) cases of TP, primarily following transsphenoidal surgery for pituitary tumors (9 cases) or Rathke cleft cysts (2 cases) were included. Common symptoms included headaches (7 cases) and visual disturbances (2 cases). TP onset ranged from two days to thirteen years after surgery, with CSF leaks, sellar defects, and inadequate packing as risk factors. Endoscopic decompression and surgical repair were the most common treatments (9 cases), while the remaining three patients were managed conservatively with antibiotics; all cases with favorable outcomes.

Our review highlights TP as a rare yet important consideration to be aware of and its variable presentation following EETS. In patients with symptomatic TP, endoscopic decompression and repair of the sellar floor with fat packing of the sphenoid sinus is acceptable. Incidentally discovered TP on postoperative scans in otherwise asymptomatic patients can be conservatively managed.