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The aim of this study is to investigate the relationships between tumor size, nasal symptoms including olfactory function, and posoperative atrophic mucosal changes after the endoscopic endonasal transsphenoidal approach (EETSA).This was a retrospective review of the medical records of 112 patients who underwent the 2 nostrils/4 hands EETSA with bilateral modified nasoseptal rescue flaps between February 2009 and January 2016. Pre- and postoperative paranasal sinus computed tomography, nasal cavity endoscopic images, the Connecticut Chemosensory Clinical Research Center (CCCRC) test, Cross-Cultural Smell Identification Test (CCSIT), the Nasal Obstruction Symptoms Evaluation, and the Sino-Nasal Outcome Test-20 were conducted. Nasal mucosal changes as determined by endoscopy were divided into 4 groups: normal to normal, Group A; atrophy to atrophy, Group B; normal to atrophy, Group C; and atrophy to more atrophy, Group D. The Mimics program was used to calculate nasal cavity volume changes after surgery.There were significant differences between pre- and postoperative olfactory function as reflected by the CCCRC (P < 0.001) and CCSIT (P < 0.001) scores. There was also a correlation between tumor size and olfactory function scores such as the CCCRC (P = 0.012) or CCSIT (P = 0.015). Moreover, nasal mucosal atrophic changes were related to tumor size and olfactory function tests.The tumor size was related to olfactory function and atrophic mucosal changes. Therefore, patients with large tumors should be informed that, after the EETSA, their olfaction may be altered and that nasal symptoms related to mucosal atrophy could occur.