# Situation: A 49-year-old man with acromegaly from a growth hormone–secreting pituitary adenoma undergoes transsphenoidal removal of the tumor. He returns to the surgical ward with nasal packing and an indwelling urinary catheter. On the first postoperative day, he says he feels a sneeze coming. Which instruction by the nurse is appropriate?

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> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 49-year-old man with acromegaly from a growth hormone–secreting pituitary adenoma undergoes transsphenoidal removal of the tumor. He returns to the surgical ward with nasal packing and an indwelling urinary catheter.

On the first postoperative day, he says he feels a sneeze coming. Which instruction by the nurse is appropriate?

## 보기

1. Let it out with your mouth open **✔ 정답**
2. Pinch your nose closed and hold it in
3. Blow your nose gently after it passes
4. Tilt your head down toward your knees

**정답: 1**

## 해설

After transsphenoidal surgery, actions that raise pressure in the nose and head — nose blowing, straining, bending forward, coughing, or sucking through a straw — can disrupt the repair of the sella. If a sneeze cannot be stopped, sneezing with the mouth open vents the pressure through the mouth instead of the nose.

## 심화 해설

Why the mouth-open sneeze is the correct instruction

After transsphenoidal removal of a pituitary adenoma, the surgical defect in the sellar floor and the nasal packing are both vulnerable to any sudden rise in intranasal and intracranial pressure. A sneeze is a forceful, involuntary expiratory event that can generate a steep pressure wave through the nasopharynx. If the mouth stays closed, that pressure is directed almost entirely into the nasal cavity and against the fresh surgical repair. Opening the mouth during a sneeze provides a low-resistance escape route for the air, so the pressure vents through the oral cavity rather than being transmitted upward through the nose toward the sella.

The goal is not to suppress the sneeze but to redirect the pressure away from the operative site. In the computational fluid dynamics study by Wu and colleagues, the authors note that patients are frequently advised to sneeze with an open mouth after endoscopic endonasal skull base approaches, and their modeling work was designed to quantify the sinus pressures generated along the skull base during sneezing [1]. The clinical rationale is that an open-mouth sneeze reduces the peak pressure delivered to the paranasal sinuses and the repaired skull base defect.

Watch out! Holding a sneeze in by pinching the nose closed is dangerous because it traps the pressure inside the nasopharynx and forces it against the surgical repair. Blowing the nose is also contraindicated because it directly elevates intranasal pressure. Bending the head down toward the knees increases intracranial venous pressure and is not a maneuver that protects the sella.

Postoperative nursing priorities after transsphenoidal surgery

Yuan emphasizes that expert nursing care after transsphenoidal pituitary tumor resection centers on early identification of pituitary dysfunction and neurosurgical complications [2]. The most directly relevant neurosurgical complication here is a cerebrospinal fluid leak, which can occur if the sellar repair is disrupted. Activities that raise pressure in the nose and head — sneezing with a closed mouth, nose blowing, straining, coughing, bending forward, or sucking through a straw — can all jeopardize the dural closure and lead to CSF rhinorrhea or pneumocephalus.

A CSF leak after transsphenoidal surgery may present as clear, watery nasal drainage that is positive for glucose or that produces a halo sign on gauze. Because the patient has nasal packing in place, the nurse must monitor for posterior drainage, a persistent salty or metallic taste, headache, or an increase in clear drainage when the patient leans forward. These findings require prompt reporting.

| Patient action | Effect on intranasal pressure | Safety after transsphenoidal surgery |
| --- | --- | --- |
| Sneeze with mouth open | Pressure vents through the mouth | Safe; preferred if sneeze cannot be stopped |
| Pinch nose and hold sneeze in | Pressure trapped and directed at the sella | Unsafe; risks disrupting the repair |
| Blow nose gently | Directly elevates nasal pressure | Unsafe; contraindicated |
| Tilt head down toward knees | Increases intracranial venous pressure | Unsafe; does not protect the surgical site |

Hormonal and fluid-status monitoring

Beyond the mechanical protection of the surgical site, the nurse must also monitor for endocrine complications. Yuan lists adrenal insufficiency, diabetes insipidus, syndrome of inappropriate antidiuretic hormone, and cerebral salt wasting syndrome as the key pituitary dysfunctions to anticipate [2]. The indwelling urinary catheter in this scenario is useful for accurate hourly urine output measurement, which is essential for detecting diabetes insipidus. Diabetes insipidus after pituitary surgery presents with a high urine output, low urine specific gravity, rising serum sodium, and increasing serum osmolality. In contrast, SIADH presents with concentrated urine, dilutional hyponatremia, and fluid retention. The nurse should monitor urine output, specific gravity, serum sodium, and daily weights while also assessing for signs of adrenal insufficiency such as hypotension, weakness, nausea, and hypoglycemia.

Key point! The immediate postoperative instruction for a sneeze is to keep the mouth open and avoid any maneuver that raises intranasal pressure. Simultaneously, the nurse must track neurologic status, nasal drainage, and fluid-electrolyte balance because CSF leak and diabetes insipidus are among the most important complications in the first 24 to 48 hours after transsphenoidal surgery [2].References (research sources)

- [1]Peak Sinus Pressures During Sneezing in Healthy Controls and Post-Skull Base Surgery Patients.Research articleWu Z, Craig JR, Maza G, Li C, Otto BA, Farag AA, Carrau RL, Zhao K. (2020) · DOI: 10.1002/lary.28400

- [2]Managing the patient with transsphenoidal pituitary tumor resection.Research articleYuan W (2013) · DOI: 10.1097/JNN.0b013e3182828e28

## 임상 시나리오

Post-Transsphenoidal Sneezing InstructionProtecting the sellar repair from pressure spikes
After transsphenoidal pituitary surgery, any action that raises intranasal pressure can disrupt the sellar floor repair and nasal packing. If a sneeze cannot be suppressed, instruct the patient to sneeze with the mouth open. This vents the pressure wave through the oral cavity instead of directing it upward toward the skull base.

Contraindicated actions include nose blowing, straining, bending forward, coughing, and sucking through a straw. These all increase pressure in the nose and head, risking CSF leak or repair disruption.

CautionNever instruct the patient to pinch the nose closed during a sneeze. This traps pressure inside the nasopharynx and forces it directly against the fresh surgical site, significantly increasing the risk of CSF leak and meningitis.

## 핵심 개념

- **Transsphenoidal surgery** — Surgical approach through the sphenoid sinus to remove pituitary tumors; leaves a sellar floor defect requiring protection from pressure.
- **Sella turcica** — Bony depression at the skull base housing the pituitary gland; its repair is vulnerable after tumor removal.
- **Acromegaly** — Condition caused by excess growth hormone, often from a pituitary adenoma, leading to enlargement of bones and soft tissues.
- **Intranasal pressure** — Pressure within the nasal cavity; sudden increases can disrupt fresh surgical repairs after endonasal procedures.
- **CSF leak** — Cerebrospinal fluid leakage through a dural defect; a major complication after transsphenoidal surgery.

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