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Morbidities Associated With the Endoscopic Transnasal Transpterygoid Approach:

Focusing on Postoperative Sequelae

Ji-Eun Choi, Yang-sub Noh, Kyung Eun Lee, Yong Gi Jung, Seung-Kyu Chung, Hyo
Yeol Kim, Doo-Sik Kong, Do-Hyun Nam, Sang Duk Hong

PII: S1878-8750(19)33051-7
DOI: https://doi.org/10.1016/j.wneu.2019.12.023
Reference: WNEU 13870

To appear in: World Neurosurgery

Received Date: 6 October 2019

Revised Date: 4 December 2019
Accepted Date: 5 December 2019

Please cite this article as: Choi J-E, Noh Y-s, Lee KE, Jung YG, Chung S-K, Kim HY, Kong D-S, Nam
D-H, Hong SD, Morbidities Associated With the Endoscopic Transnasal Transpterygoid Approach:
Focusing on Postoperative Sequelae, World Neurosurgery (2020), doi: https://doi.org/10.1016/
j.wneu.2019.12.023.

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Morbidities Associated With the Endoscopic Transnasal Transpterygoid

Approach: Focusing on Postoperative Sequelae

Short title :

Postoperative morbidity after endoscopic transpterygoid approach

Authors: Ji-Eun Choi1, Yang-sub Noh1, Kyung Eun Lee1, Yong Gi Jung1, Seung-Kyu Chung1,

Hyo Yeol Kim1, Doo-Sik Kong2, Do-Hyun Nam2, Sang Duk Hong1

Affiliation:

Department of Otorhinolaryngology-Head and Neck Surgery1, Samsung Medical Center,

Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

Department of Neurosurgery2, Samsung Medical Center, Sungkyunkwan University School

of Medicine, Seoul, Republic of Korea

Corresponding author: Sang Duk Hong, MD. PhD.

Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center,

Sungkyunkwan University School of Medicine,

81 Irwon-ro, Gangnam-gu, Seoul, 06352, Republic of Korea

TEL: 82-2-3410-3579/ FAX: 82-2-3410-6987

E-mail: kkam97@gmail.com
Key Words: Pterygopalatine fossa; skull base; endoscopic endonasal approach; sinonasal

tumor; sinonasal-related quality of life

Abstract

Objectives: Although endoscopic transpterygoid approach had been popularized, there

were no study about anatomy-specific morbidities in this approach. Purpose of this study is to

investigate the surgical morbidities associated with the endoscopic transpterygoid approach

for resection of anatomic structures.

Methods: Retrospective analysis of prospectively collected data who underwent the

endoscopic transpterygoid approach for skull base tumor by a single ENT surgeon in a

tertiary care center from November 2013 to January 2019 were performed. Postoperative

patient symptom prevalence associated with surgical findings and Sino-Nasal Outcome Test

(SNOT-22) score were included in analysis

Results: Thirty-seven consecutive patients were enrolled. The mean follow-up period

was 12.4 months (range, 1-39 months). Twenty-six (70.3%) vidian nerves were sacrificed, but

only 38.5% (10/26) of those patients complained of mild dry eye symptoms. Fourteen (37.8%)

nasolacrimal ducts were resected, with only one patient (7.1%) who had undergone previous

radiation therapy complaining of transient epiphora. SNOT-22 scores before and after surgery

did not present statistical difference in inferior turbinate sacrifice group and preservation

group.

Conclusion: Sacrifice of sinonasal structures such as the inferior turbinate or vidian

nerve is sometimes inevitable for safe tumor resection with the endoscopic transpterygoid

approach. Subjective complaints were not apparent in most cases, despite the structural

sacrifice.
ACKNOWLEDGEMENTS

none

FUNDING

This research did not receive any specific grant from funding agencies in the public,

commercial, or not-for-profit sectors.

INTRODUCTION

Introduction of the transpterygoid approach of the endoscopic endonasal technique in

20031 has expanded the boundaries and limits of endoscopic skull base surgery.2-8 This

surgical approach became the fundamental surgical method for gaining access to various

regions of skull base tumors traditionally treated with an open approach, thereby significantly

reducing potential postoperative morbidity.

The pterygopalatine fossa (PPF) represents the main pathway for spread of

inflammatory or neoplastic diseases from the skull base to the head and neck. It is located

between the posterior wall of the maxillary sinus and the pterygoid plates in a narrow space

shaped as an inverted pyramid. The boundaries of the surgical field are the pterygoid plates

posteriorly, the ascending process of the palatine bone anteromedially, the posterior wall of

the antrum anterolaterally, the pterygomaxillary fissure laterally, the middle cranial fossa and

greater sphenoid wing superiorly, and the pyramidal process of the palatine bone inferiorly.9-
11
Surgical techniques to manage this area are a challenge to many ENT surgeons not only

due to the narrow space and deep anatomy, but because the area comprises a diverse complex

array of vascular and neural structures.11

Until now, most reports have focused on surgical outcomes and broadening surgical

indications of the transpterygoid approach. Not much attention has been paid to postoperative

morbidity from the patient’s perspective. There are only two case series12,13 that have reported

the number of cases of postoperative morbidity, in addition to surgical outcome. One case

series reported by Battaglia et al.12 revealed a rate of minor complications of 13.5% (5/37),

which includes facial numbness and dry eye syndrome (DES). There are no studies

investigating subjective outcomes from the patient’s perspective in association with surgical

findings. Possible surgically-resected structures related to the transpterygoid approach are

clarified in Supplementary Figure 1.

 In our tertiary care center, we have experienced some unexpected cases either without

symptoms or with relatively non-problematic symptoms after resection of vital structural

components using the transpterygoid approach (e.g., greater palatine nerve of V2,

nasolacrimal duct, vidian nerve). With this clinical experience, we assumed that not all nerve

injuries will impact postsurgical morbidity. The primary outcome of our study was to

investigate the prevalence of postoperative morbidity, focusing on its relationship with

surgical findings. The secondary outcome was to assess sinonasal quality of life (QOL) after

the endoscopic transpterygoid approach.

MATERIALS AND METHODS

The surgical records of patients from our database of endoscopic skull base surgeries

were reviewed. We selected patients treated with endoscopic tumor resection with the

transpterygoid approach by a single ENT surgeon (S.D.H.) in our tertiary hospital from

November 2013 to January 2019. A total of 37 patients was included. Exclusion criteria were

as follows: (i) surgical procedures for the purpose of biopsy or (ii) endoscopic debridement

for inflammatory lesions. Clinical data of demographics, disease extent, surgical procedure,

intraoperative findings, and postoperative symptoms including the Sino-nasal Outcome Test

(SNOT-22) were retrieved from all patients undergoing the endoscopic transpterygoid

approach. This study was approved by the institutional ethics committee of Samsung Medical

Center in Seoul, South Korea.

Techniques and Extent of the Transpterygoid Approach

Sinonasal corridors (Table 2)

For tumors limited to around the sphenoid lateral recess or Meckel’s cave, we tried to

preserve the inferior turbinate (IT). However, if there was a limitation to safe tumor resection,
we resected the IT partially. If the tumor extended from the nasal cavity to the infratemporal

fossa or parapharynx space, we performed endoscopic medial maxillectomy with IT resection.

However, if the tumor was confined to the infratemporal fossa, we preferred prelacrimal

medial maxillectomy with or without transantral window.14

Managing PPF contents (Fig. 1)

We usually ligated the sphenopalatine artery and tried to preserve the neural contents in

the PPF. If we needed more room to dissect, we usually resected the vidian nerve and

lateralized the remnant PPF contents. If there was not enough room for dissection, the greater

palatine nerve was also resected.

Surgical Tips in Improving Surgical Field

When dissecting the pterygopalatine fossa, it is crucial to secure clear surgical view. By

reflecting on our 15 years’ of surgical experiences in skull base surgery, there are some

surgical tips. Firstly to avoid “red eye”, meticulous control of the mucosal bleeding from the

ethmoid cavity or transected turbinates is important. Secondly, sphenopalatine artery should

always be coagulated at the entry point of transpterygoid approach. And if necessary, internal

maxillary artery must be identified and should be clipped accurately. Lastly, maintaining

subperiosteal dissection is the principal key in lateralizing pterygopalatine fossa contents or

lateral pterygoid muscles to avoid tremendous bleeding from pterygoid plexus.

Surgical Morbidity and Quality-of-Life Analysis

Supplementary Figure 1 shows essential structures possibly related to patient morbidity

following the transpterygoid approach. Sinonasal-related QOL was determined by employing

the Sino-nasal outcome test (SNOT-22). Patients were asked to complete the query during
preoperative and postoperative visits, which are generally scheduled at one, three, and six

months, with added follow-up visits when necessary. It has 22 questions about sinonasal

symptoms and general aspects, each categories graded from zero to five; zero meaning no

problems and five scores for worst possible problem. This is considered as most adequate

questionnaire in evaluating quality of life of patients in rhinologic disease15,16. In addition to

the SNOT-22, the patient’s individual postoperative symptoms, such as dry eye, epiphora,

empty nose syndrome, or facial/palatal numbness, were also assessed. During postoperative

follow up, related possible complications were asked to individual patients in a open question

manner. Duration of symptoms was also evaluated and included in the analysis. Symptoms

lasting fewer than three months were categorized as transient and more than three months as

persistent.

Statistical Analysis

Standard statistical analysis was performed with the SPSS 20.0 (IBM Corp., Armonk,

NY) software. Variables were compared between the groups using Student’s t-test (or Mann-

Whitney test) or Chi-square test (or Fisher’s exact test). Paired t-test (or Wilcoxon signed

rank test) was also conducted to compare the pre- and postoperative results of the SNOT-22.

Statistical significance was assessed at the 0.05 level.

RESULTS

During the study period from November 2013 to January 2019, a total of 37 patients

underwent tumor resection via the endoscopic transpterygoid approach. The patients’

demographic data are shown in Table 1. The mean age of the study group was 45.2±17.7, and

the mean follow-up time was 12.37±9.87 months, with a range of 1-39 months. A wide

spectrum of pathologic diagnoses was observed in the study group, with the most common
pathologies being schwannoma (10/37, 27.0%) and meningioma (7/37,18.9%). Out of 10

cases of schwanomma, 9 cases were trigeminal nerve origin, and only 1 case was vidian

nerve origin. There were three V2 schwannoma and two V3 schwannoma. Other 4 cases

could not exactly classify because the epicenter of tumors were Meckel’s cave where V1, V2

and V3 is merged. According to surgical finding, we were able to dissect the tumor apart from

the nerve sheath in 1 case of V3 schwanomma and also in 1 case of V2 schwanomma.

Surgical Extent and Combined Approaches

Different extents of surgery were performed based on precise surgical mapping (Table

2). The pterygopalatine fossa was involved in 64.9% (24/37) of cases, the middle fossa in

48.6% (18/37), and the hypoglossal canal/jugular fossa in 10.8% (4/37) of patients.

Endoscopic medial maxillectomy was performed on 56.8% (21/37) of the patients, with

nasolacrimal duct preservation in 33.3% (7/21) of those cases and nasolacrimal duct sacrifice

in the other 67.7% (14/21). In the sinonasal cavity, the middle turbinate was resected in the

majority of cases (33/37, 89.2%), while inferior turbinate resection was performed in 21

patients (56.8%).

Intraoperative findings of sacrificed and resected structures are presented in Table 3. Overall,

in 70.3% (26/37) of the patients, vidian nerve sacrifice was either inevitable to obtain safe

surgical freedom or could otherwise not be conserved due to tumor involvement. The

maxillary division of the trigeminal nerve was resected in 37.8% (14/37) of the patients, with

the infraorbital nerve and the greater palatine nerve being resected in 28.6% (4/37) and 71.4%

(10/37) of those cases, respectively. As mentioned previously, the inferior turbinate was

resected in 56.8% (21/37) of the patients, while the nasolacrimal duct was resected in 37.8%

(14/37).43.2%(16/37) achieved gross total resection, 18.9%(7/37) had near total resection.

37.8% (14/37) patient had residual tumor. Ten residual tumors were intentionally left because
cavernous sinus or posterior fossa was involved. Adjuvant therapies were planned in

45.9%(17/37) and detailed treatment modality consist of gamma knife surgery (76.4%,13/17),

radiotherapy with chemotherapy (17.6%,3/17), radiotherapy alone(5.8%,1/17).

Patient Morbidity Associated With the Transpterygoid Approach

Complications associated with the transpterygoid approach were evaluated according to

intraoperative finding.

Dry Eye Syndrome After Vidian Nerve Injury

In the 26 vidian nerve sacrifice cases shown in Figure 2, 17 patients (65.4%) had no

symptoms postoperatively, five patients (19.2%) had transient dry eye syndrome, and four

patients (15.4%) had persistent dry eye syndrome. Despite prolonged dry eye syndrome, all

of these patients said it was not problematic in daily life. Among the vidian nerve

preservation group, most patients (10, 90.9%) were asymptomatic, as predicted. Only one

patient whose vidian nerve was transpositioned during the surgery had transient dry eye

symptoms.

Nerve Dysfunction After Trigeminal Nerve Injury

Overall, 77.7% (7/9) patients have complained of persistent V2 or V3 numbness

postoperatively. But 2 patients stated that they had no postoperative numbness. Detailed

analysis of each nerve origin is described below.

Facial Numbness After Maxillary Division of Trigeminal Nerve (V2)

Clinical manifestations including isolated facial hypoesthesia and paresthesia-like

tingling sensation on the greater palatine and/or infraorbital dermatome were stratified as V2
numbness. The maxillary division of the trigeminal nerve (V2) was preserved in 25 patients

(67.6%) and resected in the other 12 patients (32.4%). In the V2 preservation group (n=25),

eight patients (32.0%) developed facial numbness after surgery because of manipulation of

the nerve during the operation (transient, 5/25 (20.0%); persistent, 3/25 (12.0%)). On the

other hand, after V2 resection (n=12), 66.7% (8/12) had transient facial numbness, and only

33.3% (4/12) of the patients complained of persistent numbness. These differences were

statistically significant (P < .001).

Dysfunction of Mandibular Division of Trigeminal Nerve (V3)

In our cohort, sacrifice of the mandibular nerve was inevitable in three cases (two V3

schwannomas and one middle fossa meningioma). Subsequently, all patients developed

permanent nerve dysfunction manifesting in facial numbness and difficulty with mastication.

One patient who was diagnosed with meningioma with infratemporal fossa extension had

persisting mastication difficulty, continuously complaining of combined pain on mastication.

Additional neuropathic pain control by central neuromodulators (e.g., pregabalin and

gabapentin) and neuromuscular electrical stimulation therapy were conducted on referral to

the department of rehabilitation.

Epiphora After Nasolacrimal Duct Injury

The nasolacrimal duct was resected in 13 patients. Among resected patients, only one

(7.7%) who had a history of radiation therapy for nasopharyngeal carcinoma developed

transient epiphora seven days after surgery, but it resolved with the lacrimal duct probing

procedure.

Morbidity After Combined Inferior Turbinate Resection

 Analysis of complications in the inferior turbinate resection group (n=20) to determine

any detrimental effects on nasal function revealed no patients complaining of empty nose

syndrome. However, one patient presented with atypical nasal discomfort, specifically the

sensation of wide empty space inside, which was persistent for over one year after surgery.

Quality-of-Life Analysis

The preoperative total and subdomain SNOT-22 scores for this study are presented in

Table 4. There were no statistical differences in preoperative and postoperative SNOT-22

scores.

Next, we compared the SNOT-22 scores of the inferior turbinate preservation and

sacrifice groups to assess the impact of turbinate resection on sinonasal-related QOL.

Preoperative SNOT-22 was 16.00±23.00 in the inferior turbinate preservation group and

23.0±9.54 in the sacrifice group (P = .49). In the rhinologic subdomain SNOT-22 query, the

IT preservation group had higher baseline score compared to the IT resection group, without

statistical significance (7.25±7.63 and 3.00±4.30, respectively; P = .54). At each

postoperative period (one, three, and six months), the total score and subdomain SNOT-22

scores did not differ between groups, with the exception of the three-month postoperative

period, where the sleep domain score scored worse in the IT resection group compared to the

IT preservation (7.41±2.87 and 2.85±2.64 , respectively; P = .007). Also, similarly in

psychological domain, IT resection group tend to have higher points at postoperative 3month

and 6month but did not reach statistical significance (p=0.13, 0.08). Results of each group are

simplified in graphs in Figure 4.

DISCUSSION

Further development in endoscopic endonasal surgery regarding exploration beyond the

pterygopalatine fossa have improved access and visualization over the last few decades.

Diverse surgical situations and extents including the infratemporal fossa and upper

parapharyngeal spaces have been managed.17 There is accumulating evidence confirming the

feasibility and safety of this minimally invasive approach.

Surgical pitfalls of this approach lie in its limited dimensions containing a large variety

of delicate and critical vascular and neural elements. Although there may be some anatomical

variations, integrative surgical mapping is essential and must be completely understood and

manipulated with caution during surgery.17,18

Despite the widespread adoption of the surgical approach, related postoperative

complications have not been well defined. Consequently, there are uncertainties in patient

counselling before and after surgery. The principal finding of this current study is that

sacrifice of the vidian nerve, which is one of the most critical elements of the transpterygoid

approach, resulted in persistent dry eye syndrome in only 15.4% (4/26) of patients, while 19.2%

(5/26) had transient dry eye syndrome, and the majority (17/26, 65.4%) was asymptomatic.

These results imply that, even though there are violations of the vidian nerve, not all patients

with neural injury experienced impact on function. Furthermore, among patients with vidian

nerve sacrifice whom presented dry eye syndrome (10/26) did not exhibit significant

differences in age compared to whom was asymptomatic (46.0±18.40 vs 33.0±15.93, p=0.13)

There have been many debates about this kind of phenomenon in other surgical fields;

for example, in vidian neurectomy, which is a surgical treatment for medically refractory

vasomotor rhinitis.19-21 Not only unilateral nerve resection cases, but also bilateral vidian

neurectomy resulted in low reported rates of dry eye syndrome.20 In a recent study, Su et al.19

pointed out that compensation from the continuous neural drive in the sphenopalatine

ganglion (synaptic plasticity) may explain the restoration of sufficient tear flow after vidian

neurectomy.19 On the other hand, sacrifice of the maxillary nerve (V2) resulted in facial
numbness in all patients (transient vs permanent, 66.7% vs 33.3%). In the preservation group,

32% (8/25) of patients developed facial numbness after surgery, mostly transient. This

finding could be explained by the regional anatomic distribution of V2 along the surgical

field, which depends on tumor location. Manipulation of the greater palatine nerve bundle is

sometimes unavoidable because of surgical freedom.

After nasolacrimal duct resection, only one patient complained of transient epiphora.

The symptom resolved with probing the nasolacrimal duct and did not require further

treatment. The history of radiation therapy in this patient could explain the transient

obstruction. To decrease the rates of epiphora after nasolacrimal duct resection, we usually

cut the nasolacrimal duct clearly using cold instruments and avoid cauterization. This

technique might be the reason for the low incidence of complications following nasolacrimal

duct injury.

Recent trends in outcome reporting have more strongly emphasized patient perception,

such as QOL, as the main judgement factor for evaluating success of surgery. Several prior

studies have assessed the QOL outcomes and reported that short-term postoperative QOL was

better in patients who underwent the endoscopic approach in comparison with the subcranial

approach.22 Moreover, sinonasal QOL in the immediate postoperative period of 3-12 weeks

worsened but returned to baseline score three to six months after endoscopic pituitary

surgery.23,24 However, controversy remains regarding sinonasal morbidity of the endonasal

approach, and many studies are ongoing.25 Furthermore, the effect of the transpterygoid

approach on sinonasal QOL remains undefined.

To our knowledge, this is the first study to demonstrate sinonasal-specific QOL in

patients undergoing the transpterygoid approach. Increased rates of resection can improve

visualization provided by the endoscope, thereby assuring easier and safer surgical

management of the lesion. However, resection of the inferior turbinate to enhance access
might at the same time result in empty nose syndrome. In our cohort, there were no changes

from pre- to postoperative SNOT-22 scores overall, nor in any subdomain of SNOT-22. In

subgroup comparison of turbinate preservation and resection, there were no overall

significant differences in SNOT-22 score except sleep domain at 3months. On the other hand,

there was a tendency in progressive worsening observed in subdomains of sleep and

psychological domain. However, these differences require long term follow up more than 5

years. It is notable that despite inferior turbinate resection, only one patient complained of the

persistent atypical nasal symptom that is the feeling of wide space inside the nasal cavity;yet,

it was not bothersome to this patient. Although the follow-up period was not long enough,

resection of the inferior turbinate did not result in empty nose syndrome, at least not in short-

term follow up.

Detailed analyses of complications are essential in understanding surgical procedures.

We believe that this study can provide some valuable information about the prevalence of

postoperative complications and the importance of patient counselling prior to performing the

endoscopic transpterygoid approach.

Study Limitations

This study contained potential limitations. Some limitations are inherent because the

study was retrospective in nature and only considered the experience of a single institution.

Further studies with enrollment of larger patient groups are required to provide better

estimates of postoperative morbidity. Also, the mean follow up period of 1 year (12.37±9.87)

with a range of 1-39months. Since there are heterogenecity in follow up durations, this might

unable to truly reveal long term morbidity associated with transpterygoid approach.

Especially in assessing empty nose syndrome, it usually requires more than 12 months of

disturbed endonasal turbulence to become clinically relevant if only one nasal side is
operated on. More clinical data with long term follow up is needed to validate.

In addition, we collected postoperative symptom data, including paresthesia, dry eye

syndrome, and epiphora, in an open question manner at each follow up periods. But in

cases of facial/palatal numbness, we performed classic cranial nerve examination localizing

each trigeminal nerve dimensions by light touch using a cotton wisp or tissue paper were

performed to confirm at first complaint. But unfortunately, we did not check more during

follow ups. Patients complaining epiphora were recommended on consultation promptly to

ophthalmologist. As stated in the result, only 1 patient out of 13 patients with nasolacrimal

duct sacrifice developed this symptom one week after surgery, but it resolved with the

lacrimal duct probing procedure. Self-reporting outcomes like VAS, SNOT-22 may aid in

validation of the impact on patient QOL and also objective findings like neurologic

examination, Schirmer’s test for dry eye syndrome would be an invaluable composite but we

would like to subject this point to further studies for verification. Even though each related

complications are asked to individual patients, this way could underrate precise incidence.

Notwithstanding the aforementioned limitations, this is the first study to comprehensively

combine possible morbidity associated with the transpterygoid approach using conventional

techniques. Further prospective studies incorporating questionnaires, objective measures

regarding the transpterygoid approach might provide more precise information.

To conclude, surgeons must pay attention in patient counselling regarding postoperative

surgical morbidity. It is mandatory that accurate information be provided about potential

postsurgical morbidities in various situations that may be encountered during surgery. The

results of our study indicate that the endoscopic transpterygoid approach in treatment of skull

base lesions of varying extent and pathology has a relatively low prevalence of surgical

morbidity despite the greater structural sacrifice.

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Figure 1. Representative cases showing adjacent relationship with vital neural structure
Case1: A; MRI image in patient with left sphenoid lateral recess meningoencephalocele D;
Vidian nerve (asterisk) preserved during surgery
Case2: B; Axial image of preoperative MRI of trigeminal schwanomma extending to
cavernous sinus, nasopharynx. Due to extensive tumor extent, resection of vidian nerve
(asterisk) and greater palatine nerve (arrow) was inevitable during surgery.(E)
Case3: C,F; Hugh schwanomma with infratemporal fossa extension (vidian nerve canal
origin). Greater palatine nerve (arrow) was preserved in spite of close location of tumor, but
to directly assess lesion, manipulation of the neural structure seems to be unavoidable by
surgical instrument.
Figure 2. Postoperative surgical morbidity in correlation with sacrificed structure

A: Dry eye syndrome prevalence in vidian nerve sacrifice cases(N=26); vidian nerve
preservation cases (N=11) (p=0.406)
B: Postoperative V2 numbn.ess after V2 sacrifice (N=12) ; V2 preservation(N=25)
(p<0.001)
C: Epiphora after resection of nasolacrimal duct (N=13); NLD preservation cases(N=24)
VN, vidian nerve; V2,maxillary division of trigeminal nerve; NLD.nasolacrimal duct;
Figure 3. Sinonasal function assessment after surgery

A. Pre-, postoperative SNOT-22 in all subjects (n=37) after surgery (no statistical
significant difference)
B. Subgroup comparison of SNOT-22 between inferior turbinate preservation (n=16)
and sacrifice group (n=21). There were no statistical difference between groups in pre-,
postoperative follow up at 3months.
C. Rhinologic subdomain of SNOT-22 also demonstrated no statistical difference
among each two groups.
IT; inferior turbinate *p<0.05, statistical significance
Table 1. Patient Demographics

Total (N = 37)

Age at surgery 45.2 ± 17.7

Gender No. (%)
Male 14(37.8%)
Female 23(62.1%)
Diagnosis Schwanomma 10(28%)
Meningioma 7(19%)
Angiofibroma 6(16%)
Meningocele 3(8%)
Melanoma 2(5%)
Osteosarcoma 2(5%)
Chondrosarcoma 2(5%)
Etc 5(14%)
Follow-up duration 12.37 ± 9.87 month (1-39 month)

Abbreviation: Etc, Harmatoma, paraganglioma, chordoma, IgG4-related disease

Table 2. Surgical Extent and Techniques

No.(%)

Tumor subsite
Pterygopalatine fossa 24(64.9%)
Infratemporal fossa 18(48.6%)
Sphenoid 20(54.1%)
Cavernous 21(56.8%)
Nasopharynx 16(43.2%)
Middle fossa 18(48.6%)
Hypoglossal canal/Jugular foramen 4(10.8%)
Surgical approach
Medial maxillectomy
NLD preserve 7(18.9%)
NLD sacrifice 14(37.8%)
Prelacrimal approach 4(10.8%)
Denker 3(8.1%)
Caldwell-Luc approach 4(10.8%)
MT resection 33(89.2%)
 IT resection 21(56.8%)
Reconstruction method
Nasoseptal flap 22(59.5%)

Abbreviation: NLD, nasolacrimal duct; MT, middle turbinate; IT, inferior turbinate

Table 3. Surgical Information About the Sacrificed Structures

No. %

Vidian nerve sacrifice 26 (70.3%)

Infraorbital nerve 4(10.8%)
V2 sacrifice
Greater palatine nerve 10(27.0%)
V3 sacrifice 2 (5.4%)
MT resection 33(89.2%)
IT resection 21(56.8%)
NLD resection 14(37.8%)

Abbreviation: V2, maxillary branch of trigeminal nerve; V3, mandibular branch of trigeminal nerve; MT, middle turbinate; IT, inferior
turbinate; NLD, nasolacrimal duct
 Table 4. Sinonasal-Related Quality of Life According to Inferior Turbinate Sacrifice

Preoperative Postoperative ３Month Postoperative 6Month

SNOT-22 IT IT IT IT IT
Total p Total IT sacrifice, p Total p
preserve sacrifice, preserve preserve Sacrifice
n=12 value n=21 n=11 value N=18 value
n=4 n=8 n=10 n=9 n=9

Total 20.67±10.42 16.00±23.00 23.0±9.54 0.49 23.52±11.72 20.87±15.56 25.15±8.95 0.31 20.72±13.49 17.87±11.86 23.0±14.87 0.26

Rhinologic 4.42±5.66 7.25±7.63 3.00±4.30 0.55 8.00±4.49 9.00±5.29 7.37±4.03 0.93 6.00±4.70 5.87±3.09 6.10±5.85 0.57

Extranasal 0.60±1.07 1.50±2.12 0.37±0.74 0.63 3.05±2.23 2.85±2.79 3.16±2.12 0.30 1.65±1.62 1.75±1.48 1.56±1.81 0.82

Ear/Facial pain 4.22±3.80 2.50±0.71 4.5±3.96 0.23 4.63±3.58 3.60±2.01 5.80±3.82 0.13 3.29±3.22 3.62±3.02 3.00±3.53 0.93

Psychological 9.33±5.22 7.50±0.71 9.62±5.5 0.34 6.53±4.33 3.71±2.98 8.15±4.21 0.13 7.94±5.99 5.75±4.33 9.89±5.80 0.08

Sleep 9.11±4.94 6.80±6.36 9.50±5.12 0.76 5.39±3.26 2.85±2.64 7.41±2.87 0.007* 5.00±3.60 3.37±7.65 7.66±3.96 0.08

*Statistically significant.
Abbreviation: IT, inferior turbinate; SNOT-22, Sino-Nasal Outcome Test-22
Supplementary figure 1.
Anatomic representation of surgical corridors in transpterygoid approach in coronal (A),
axial view (B). VN, Vidian nerve; PPG, pterygopalatine ganglion;V2,maxillary branch of
trigeminal nerve; GPN, greater palatine nerve; Lat.ptery.muscle; Lateral pterygoid muscle;
NLD, nasolacrimal duct; IT, inferior turbinate;
Author contribution

Authors:
Ji-Eun Choi: Data curation, Writing- Original draft preparation.
Yang-sub Noh: Visualization, Investigation
Kyung Eun Lee: Data curation
Yong Gi Jung, Seung-Kyu Chung, Hyo Yeol Kim
: Conceptualization, Methodology, Software, Supervision
Doo-Sik Kong, Do-Hyun Nam : Supervision
Sang Duk Hong: Writing- Reviewing and Editing,
 Abbreviations list

DES dry eye syndrome

IT inferior turbinate

MT, middle turbinate

NLD, nasolacrimal duct

PPF pterygopalatine fossa

QOL quality of life

SNOT-22 Sino-nasal Outcome Test

S.D.H. Sang Duk Hong (corresponding author described on methods)

V2, maxillary branch of trigeminal nerve

V3, mandibular branch of trigeminal nerve