A Prospective Case-Control Study of Intraoperative Factors Contributing to Silent Aspiration and Postoperative Pulmonary Complications in Endoscopic Endonasal Skull Base Surgery

Abstract Silent aspiration of fluids or blood may occur during endoscopic endonasal surgery (EES) of the skull base. This study aims to characterize factors that may contribute to silent intraoperative aspiration and the development of postoperative pulmonary complications (PPCs) during EES. Prospective study. Single institution, tertiary academic center. A total of 101 EES cases from August 2023 to September 2024. Clinically significant PPC within 30 days of surgery. Variables assessed included clinicodemographic factors spanning preoperative, intraoperative, and postoperative periods. The average age was 54.61 ± 15.50 years and 53.47% were females. The incidence of PPC was 20.08%. PPC was associated with advanced age (p = 0.044), higher intraoperative irrigation (p = 0.001), greater blood loss (p = 0.009), longer surgeries (p < 0.001), prolonged intubation (p < 0.001), postoperative CSF leak (p = 0.004), and prolonged hospitalization (p < 0.001). In multivariable logistic regression, significant independent predictors included volume of irrigation (OR: 1.49, 95% CI: 1.08 to 2.05, p = 0.015) and duration of intubation (OR: 1.62, 95% CI: 1.27 to 2.06, p < 0.001). ETT cuff pressures were outside the recommended range both pre-surgery and post-surgery. A control group of meningioma patients treated with open craniotomy during the same time period showed a similar rate of PPC (18%) but did not demonstrate similar risk factors as the EES cohort. Different surgical approaches pose variable risk factors for PPC. In this case-control study, we highlight that skull base surgeons should recognize that duration of intubation and high volume of surgical field irrigation are major risk factors for PPC in EES.