Can a 50‑year‑old male with prior endoscopic transsphenoidal resection of a pituitary macroadenoma, residual sellar‑suprasellar mass, severe progressive visual loss, mild anemia, controlled hypertension, normal endocrine function, and chronic right otomastoiditis on ampicillin/sulbactam be cleared for repeat endoscopic endonasal transsphenoidal surgery?

Clearance for Repeat Transsphenoidal Surgery

This patient should NOT be cleared for surgery until two critical modifiable risk factors are addressed: celecoxib must be discontinued at least 7–10 days preoperatively, and the active right otomastoiditis must be fully treated with documented clinical and radiographic resolution. 1

Absolute Surgical Indication Confirmed

The combination of persistent bilateral hemianopsia, severe visual acuity loss (counting fingers OD, 20/400 OS), and a residual 2.4 × 2.4 × 3.4 cm sellar-suprasellar mass constitutes an absolute indication for repeat endoscopic transsphenoidal surgery. 1 The direct mass effect on the optic chiasm creates imminent risk of irreversible visual deterioration, making surgical decompression medically necessary. 1 Both the Congress of Neurological Surgeons and the American Association of Neurological Surgeons recommend transsphenoidal surgery as first-line therapy for symptomatic non-functioning adenomas causing visual field defects. 2, 3

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Critical Barriers to Clearance (Must Be Resolved)

1. NSAID Use – High Bleeding Risk

• Celecoxib 200 mg twice daily must be discontinued at least 7–10 days before surgery because it markedly increases intraoperative bleeding risk in transsphenoidal procedures. 1
• Fatal postoperative hemorrhage (internal carotid pseudoaneurysm rupture) has been reported when NSAIDs were continued during resection of vascularized sellar masses. 1
• Switch to acetaminophen for analgesia, which can be used safely perioperatively. 1

2. Active Otomastoiditis – Infection Risk

• The ongoing right otomastoiditis is an active infectious focus that raises the risk of postoperative meningitis. 1
• The full course of sultamicillin 750 mg TID must be completed, and clinical/radiographic resolution must be confirmed before proceeding. 1
• Nearly all cases of meningitis after transsphenoidal surgery are preceded by postoperative CSF leak; an active infectious focus compounds this risk substantially. 4

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Acceptable Pre-operative Parameters

Hemodynamic Stability

• Blood pressure 110/90 mmHg, well-controlled on amlodipine 10 mg, may be continued perioperatively. 1
• Continue amlodipine for blood pressure management throughout the perioperative period. 1

Hematologic Status

• Mild anemia (hemoglobin 11.4 g/dL, hematocrit 0.34) is acceptable for surgery. 1
• Platelet count of 264 × 10⁹/L provides adequate hemostasis. 1

Endocrine Function

• Normal cortisol (11.07 µg/dL) and ACTH (36.29 pg/mL) indicate preserved corticotroph function. 1
• Normal prolactin (13.46 ng/mL), growth hormone (0.074 ng/mL), and IGF-1 (67.82 ng/mL) exclude a hyperfunctioning adenoma. 1
• Low-normal free T4 (0.77 ng/dL) with normal TSH (1.11 µIU/mL) suggests evolving central hypothyroidism; close monitoring is required but does not contraindicate surgery. 1
• The planned hydrocortisone stress-dose protocol (100 mg IV at induction, then 50 mg q8h) is appropriate given borderline low free T4. 1

Metabolic and Renal Status

• Electrolytes are within normal limits (Na 140, K 3.46, Cl 105 mmol/L). 1
• Blood glucose is adequately controlled (capillary values 119–147 mg/dL). 1
• Renal function is preserved (creatinine 86.87 µmol/L). 1

Neurologic Status

• Glasgow Coma Scale 15, fully oriented, no focal deficits aside from visual field loss. 1
• No signs of increased intracranial pressure or acute hydrocephalus on recent imaging. 1

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Additional Pre-operative Requirements

Imaging for Surgical Planning

• High-resolution contrast-enhanced pituitary protocol MRI is the gold standard for delineating residual sellar lesions and planning the approach. 1, 5
• Obtain an updated MRI if the previous study is older than 2–4 weeks, as early postoperative changes (hemorrhage, fluid, fat graft) markedly hinder interpretation of residual tumor. 6
• Thin-slice CT of the sphenoid sinus should be obtained for navigation to evaluate septal anatomy and detect any bony dehiscence over the internal carotid arteries. 1
• Consider CT angiography to map vascular anatomy for navigation in revision cases. 1

Polyuria Monitoring

• Polyuria (approximately 4.8 L urine output in 24 hours) raises concern for developing diabetes insipidus. 1
• Perioperative monitoring is advised but does not preclude surgery. 1
• Postoperative arginine vasopressin deficiency occurs in 26% of cases and SIADH in 14% of cases after transsphenoidal surgery. 2

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Surgical Approach Considerations

• Endoscopic transsphenoidal resection is recommended because it provides superior visualization of residual tumor compared with microscopic approaches, facilitating more complete removal. 2, 3
• Optimal bony exposure of the sphenoid and sellar regions is critical, as adequate exposure directly improves the extent of tumor resection. 2, 5
• For this residual mass with suprasellar extension, endoscopic visualization after initial resection frequently reveals additional residual tumor tissue. 2, 5
• Intraoperative MRI is not recommended despite improving gross total resection rates, due to increased false-positive rates requiring extensive experience in interpretation. 2, 3

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Mandatory Post-operative Monitoring

• Minimum 2-day inpatient observation is recommended after extended transsphenoidal surgery. 1
• Monitor urine output closely for diabetes insipidus: check for output >200 cc/hr for two consecutive hours. 1
• Check serum sodium every 6–12 hours during the first 48 hours. 1
• Perform serial visual field and acuity examinations to assess surgical efficacy. 1
• Repeat comprehensive endocrine evaluation at 6–12 weeks postoperatively to detect delayed hypopituitarism. 1

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Common Pitfalls to Avoid

• Failure to discontinue NSAIDs is the most common modifiable cause of catastrophic intraoperative hemorrhage in revision transsphenoidal surgery. 1
• Operating in the presence of active infection (otomastoiditis) dramatically increases meningitis risk, especially given the high rate of postoperative CSF leak in revision cases (Knosp grade >2 is associated with perioperative CSF leak). 4
• Over-reliance on early postoperative imaging (within 3 months) leads to misinterpretation of residual tumor versus postoperative changes (hemorrhage, edema, fat graft). 6
• Underestimating the severity of postoperative water metabolism disturbances; failure to monitor closely can result in significant morbidity. 3