Is a 50‑year‑old man with a residual 2.4 × 2.4 × 3.4 cm sellar‑suprasellar mass causing persistent visual impairment, stable vital signs, mild anemia, low‑normal free thyroxine, normal cortisol and thyroid‑stimulating hormone, controlled hypertension on amlodipine, ongoing oral sultamicillin for chronic otomastoiditis, and current celecoxib use medically cleared for repeat transsphenoidal surgery?

Medical Clearance for Repeat Transsphenoidal Surgery

Yes, this patient can be medically cleared for repeat transsphenoidal surgery, but only after addressing two critical modifiable risk factors: discontinuing celecoxib at least 7-10 days preoperatively to minimize bleeding risk, and completing antibiotic therapy for the acute-on-chronic otomastoiditis to reduce infectious complications.

Surgical Indication Assessment

The presence of persistent bilateral hemianopsia with severely impaired visual acuity (counting fingers OD, 20/400 OS) combined with a residual 2.4 × 2.4 × 3.4 cm sellar-suprasellar mass represents an absolute indication for repeat surgical intervention to prevent permanent visual loss. 1, 2

• Mass effect on the optic chiasm creates imminent risk for irreversible visual deterioration, making surgical decompression medically necessary 2
• The transsphenoidal approach is appropriate for residual/recurrent sellar-suprasellar masses, with literature supporting gross total resection rates of 79-81.8% even in revision cases 3, 4, 5

Critical Preoperative Risk Factors Requiring Modification

1. NSAIDs/Celecoxib - MUST BE DISCONTINUED

Celecoxib 200mg BID must be stopped at least 7-10 days before surgery due to significant bleeding risk in transsphenoidal procedures. 6

• The literature documents fatal postoperative hemorrhage (internal carotid pseudoaneurysm rupture) in transsphenoidal resection of vascularized sellar masses 6
• Alternative pain management with acetaminophen is acceptable and already on the medication list
• This is a non-negotiable modification before surgical clearance

2. Active Otomastoiditis - REQUIRES TREATMENT COMPLETION

The acute-on-chronic right otomastoiditis documented on both preoperative and postoperative CT scans represents an active infectious focus that increases risk of postoperative meningitis. 7

• Postoperative sellar infections occur in 14% of extended transsphenoidal approaches and can be life-threatening 3
• The patient is currently on sultamicillin 750mg TID, which should be continued until clinical and radiographic resolution is confirmed 7
• Delayed postoperative sellar infections can occur years after surgery when foreign material (bone cement, fat grafts) is used for reconstruction 7

Favorable Medical Parameters

Hemodynamic Stability

• Blood pressure 110/90 mmHg is well-controlled on amlodipine 10mg, which can be safely continued perioperatively
• No evidence of hemodynamic instability or cardiovascular compromise

Hematologic Status

• Hemoglobin 114 g/L and hematocrit 0.34 represent mild anemia but are acceptable for surgery
• Platelet count 264 × 10⁹/L is adequate for hemostasis
• WBC 9.1 × 10⁹/L with normalized differential (N 0.49, L 0.39) indicates resolved acute inflammatory response from initial surgery

Endocrine Function

• Low-normal FT4 (0.77 pmol/L, reference 0.78-2.19) with normal TSH (1.11 mIU/L) suggests evolving central hypothyroidism requiring close monitoring but not contraindication to surgery 1
• Normal cortisol (11.07 μg/dL) and ACTH (36.29 pg/ml) indicate preserved corticotroph function
• Normal prolactin, growth hormone, and IGF-1 rule out hyperfunctioning adenoma

Metabolic Status

• Electrolytes within normal limits (Na 140.24, K 3.46, Cl 105.15)
• Urine output pattern shows polyuria (4800 mL on most recent day vs 1150 mL intake), raising concern for evolving diabetes insipidus that requires perioperative monitoring but does not preclude surgery
• Blood glucose control adequate (CBG 120-147 mg/dL range)
• Renal function preserved (creatinine 86.87 μmol/L)

Neurologic Status

• GCS 15, fully oriented, no focal deficits except visual field defects
• Intact cranial nerves (except CN II compromise from mass effect)
• No signs of increased intracranial pressure or hydrocephalus on recent imaging

Imaging Considerations for Surgical Planning

The postoperative CT demonstrates expected changes including decreased mass size, air locules in the sella, and post-surgical hematoma in the sphenoid sinus, without acute hemorrhage or infarction. 6

• High-resolution MRI with contrast remains the gold standard for surgical planning of residual sellar masses 6, 1
• Thin-cut CT through the sphenoid sinus should be obtained for intraoperative navigation, particularly to assess septal anatomy and identify any bony dehiscence over the internal carotid arteries 6
• The presence of polysinus disease and sphenoid sinus hematoma may complicate the surgical corridor but does not contraindicate repeat transsphenoidal approach 4, 5

Specific Perioperative Management Requirements

Preoperative Checklist

• Discontinue celecoxib ≥7-10 days before surgery (switch to acetaminophen for pain control)
• Complete antibiotic course for otomastoiditis (confirm clinical resolution before proceeding)
• Obtain updated MRI with thin-section pituitary protocol if >2-4 weeks from last imaging 6
• Consider CT angiography for surgical navigation given previous surgery and need to identify vascular anatomy 6
• Continue amlodipine perioperatively for blood pressure control
• Stress-dose corticosteroids may be needed given borderline-low FT4, though baseline cortisol is normal 1

Intraoperative Considerations

• Extended endoscopic endonasal transsphenoidal approach is appropriate for this residual suprasellar mass 4, 5
• The virgin surgical plane from below (since previous surgery was also transsphenoidal) may be more challenging than transcranial revision, but literature supports 79-81.8% gross total resection rates in revision transsphenoidal cases 3, 5
• Meticulous closure of skull base defect is critical given the 13.6% CSF leak rate in revision cases 5

Postoperative Monitoring (2-day minimum inpatient stay per guidelines) 2

• Monitor for diabetes insipidus (given preoperative polyuria pattern and risk of stalk manipulation)
• Serial visual field and acuity assessments
• Electrolyte monitoring (sodium every 6-12 hours for first 48 hours)
• Watch for CSF rhinorrhea (occurs in 5-14% of extended approaches) 4, 5
• Monitor for meningitis (14% risk in extended approaches) 3
• Repeat endocrine evaluation 6-12 weeks postoperatively 1

Common Pitfalls to Avoid

• Do not proceed with surgery while patient is on celecoxib - the bleeding risk in transsphenoidal surgery is substantial, with documented fatal hemorrhagic complications 6
• Do not underestimate the infection risk from active otomastoiditis - sellar infections can be life-threatening and may not manifest for years after surgery 7
• Do not assume normal pituitary function based on single preoperative labs - the low-normal FT4 and polyuria pattern suggest evolving hypopituitarism requiring close monitoring 1
• Do not rely solely on MRI for surgical navigation - thin-cut CT provides superior bony detail for sphenoid sinus anatomy and identification of carotid artery dehiscence 6