The Nasal Gateway for Pituitary Surgery

1988 ◽  
Vol 2 (4) ◽  
pp. 193-200 ◽  
Author(s):  
Mary D. Lekas
Keyword(s):  
Pituitary Gland ◽  
Sella Turcica ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
External Rhinoplasty

There has been an evolution in the transseptal transsphenoidal approach for pituitary surgery. The nasal approach to the pituitary gland can be from the sublabial transseptal transsphenoidal; the transseptal transsphenoidal; the alotomy transseptal transsphenoidal; the external rhinoplasty transsphenoidal; the transnasal by mobilizing the whole nose on a pedicle; the transseptal infranasal; the midline columellar incision; all types of nasofacial incisions; and transethmoidal approach with nasal instrumentation. The transsphenoidal hypophysectomy surgery has become a safe and effective approach for pituitary tumors. We are mainly concerned with the transnasal and not the transethmoidal approach to the sella turcica at this time.

scholarly journals Late Occurrence of Sphenoid Pyocele after Pituitary Surgery

2016 ◽  
Vol 06 (01) ◽  
pp. 044-046
Author(s):  
George Kovoor ◽  
Kamble Harsha ◽  
Akash George ◽  
Venkat Reddy
Keyword(s):  
Minimally Invasive ◽  
Female Patient ◽  
Rare Case ◽  
Sella Turcica ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Effective Procedure ◽  
Morbidity And Mortality ◽  
Transsphenoidal Approach ◽  
Patient Morbidity

The transsphenoidal approach to lesions of the sella turcica, especially for pituitary tumors, has been favored by neurosurgeons because of decreased perioperative patient morbidity and mortality of this approach compared with others. It is widely accepted because of its minimally invasive and maximally effective procedure. We report a rare case of a 63-year-old female patient with the asymptomatic delayed occurrence of sphenoid pyocele, 6 years after the initial pituitary surgery, and remained asymptomatic during this long interval.

scholarly journals Trans-nasal Trans-sphenoidal Endoscopic Hypophysectomy

2017 ◽  
Vol 53 (04) ◽  
pp. 210-221
Author(s):  
Saurabh Varshney
Keyword(s):  
Sella Turcica ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Sinus Surgery ◽  
Subtotal Resection ◽  
Transnasal Approach ◽  
Average Hospital ◽  
Invasive Approach ◽  
Female Ratio

ABSTRACTAdvances in optics, miniaturization, and endoscopic instrumentation have revolutionized surgery in the past decades. Current progress in the field of endoscopy promises to further this evolution: endoscopic telescopes and instruments have improved upon the optical and technical limitations of the microscope, and require an even less invasive approach to the sella. The minimally invasive endoscopic pituitary surgery is performed through the natural nasal pathway without any incisions and is performed via Trans-nasal Trans-sphenoidal approach. pituitary surgery is traditionally within the realm of the neurosurgeon. However, since the introduction of the endoscopic transnasal transsphenoidal approach to the sella turcica for resection of pituitary adenoma, otolaryngologists have been active partners in the surgical management of these patients. Otolaryngologists have lent their expertise in nasal and sinus surgery, assisting the neurosurgeon with the operation. The otolaryngologist has the advantage of familiarity with the techniques and instruments used to gain exposure of the sella turcica by transnasal approach. Hence, the otolaryngologist provides the exposure, and the neurosurgeon resects the tumour. Such collaboration has resulted in decreased rates of complication and morbidity.We hereby discuss our experience of treating 72 cases of pituitary tumour by endoscopic trans-nasal trans-sphenoidal approach. In our study, conducted from 2005 to 2016, the mean age of patients was 32.5 years (18-56 years), Male and female ratio was 1.3:1.0, MRI was done in all the cases, CT scan was done in 94.44 % cases, 9.72% cases had Intra op./ post op. complications which were managed successfully. Subtotal resection could be done in 6.94% cases, recurrence was seen in 7.46% cases and lumbar drain was required in 4.17 % cases. Average hospital stay was 4.4 days and average surgery time was 120 minutes. Close follow-up was maintained for an average period of 09 months. In our experience of 10 years, adopting the endoscope heightens the surgeons' visualization of pituitary tumors, thus no external incision, no nasal packing and minimal stay with minimal complications. Endoscopic transsphenoidal approach is the less traumatic route to the sella turcica, avoiding brain retraction, and also permitting good visualization, with lower rates of morbidity and mortality.

scholarly journals Metastases to the pituitary gland

2004 ◽  
Vol 16 (4) ◽  
pp. 1-4 ◽  
Author(s):  
Daniel R. Fassett ◽  
William T. Couldwell
Keyword(s):  
Pituitary Gland ◽  
Diabetes Insipidus ◽  
Skull Base ◽  
Survival Rates ◽  
Tumor Resection ◽  
Sella Turcica ◽  
Pituitary Tumors ◽  
Visual Field Defects ◽  
Malignant Neoplasms ◽  
Pituitary Metastases

Only 1% of all pituitary surgeries are performed to treat tumors that have metastasized to the pituitary gland; however, in certain cases of malignant neoplasms pituitary metastases do occur. Breast and lung cancers are the most common diseases that metastasize to the pituitary. Breast cancer metastasizes to the pituitary especially frequently, with reported rates ranging between 6 and 8% of cases. Most pituitary metastases are asymptomatic, with only 7% reported to be symptomatic. Diabetes insipidus, anterior pituitary dysfunction, visual field defects, headache/pain, and ophthalmoplegia are the most commonly reported symptoms. Diabetes insipidus is especially common in this population, occurring in between 29 and 71% of patients who experience symptoms. Differentiation of pituitary metastasis from other pituitary tumors based on neuroimaging alone can be difficult, although certain features, such as thickening of the pituitary stalk, invasion of the cavernous sinus, and sclerosis of the surrounding sella turcica, can indicate metastasis to the pituitary gland. Overall, neurohypophysial involvement seems to be most prevalent, but breast metastases appear to have an affinity for the adenohypophysis. Differentiating metastasis to the pituitary gland from bone metastasis to the skull base, which invades the sella turcica, can also be difficult. In metastasis to the pituitary gland, surrounding sclerosis in the sella turcica is usually minimal compared with metastasis to the skull base. Treatment for these tumors is often multimodal and includes surgery, radiation therapy, and chemotherapy. Tumor invasiveness can make resection difficult. Although surgical series have not shown any significant survival benefits given by tumor resection, the patient's quality of life may be improved. Survival among these patients is poor with mean survival rates reported to range between 6 and 22 months.

Endoscopic Transnasal Pituitary Surgery: Report on 180 Cases

2001 ◽  
Vol 15 (4) ◽  
pp. 281-287 ◽  
Author(s):  
Shawn S. Nasseri ◽  
Jan L. Kasperbauer ◽  
Scott E. Strome ◽  
Thomas V. McCaffrey ◽  
John L. Atkinson ◽  
...  
Keyword(s):  
Operative Time ◽  
Operative Procedure ◽  
Full Range ◽  
Sella Turcica ◽  
Length Of Hospital Stay ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Transnasal Approach ◽  
Endoscopic Transnasal Approach ◽  
Revision Operations

The endoscopic transnasal approach is an evolving technique for treating lesions in the sella turcica. Since this method was introduced at our institution 4 years ago, the majority of transsphenoidal procedures are performed with it. The records of all patients having endoscopic transnasal hypophysectomy at the Mayo Clinic during the last 4 years were reviewed retrospectively. The criteria analyzed were safety, functional and cosmetic outcome, and complications. During the 4-year period, the operative procedure was modified to improve operative exposure and safety. The results of our review showed a significant decrease in length of hospital stay, reduced operative time, reduced need for nasal packing, and elimination of a sublabial incision. The complication rate was equivalent to that reported for the traditional transseptal transsphenoidal approach. As the neurosurgeons at our institution gained experience with this approach, an increasing number of pituitary microadenomas were resected safely and successfully. In addition, because of the limited septal dissection, this approach is particularly helpful for revision operations. This approach also can be used for the full range of pituitary lesions and in conjunction with adjunctive techniques, including frontal craniotomy and -knife irradiation. Currently, the endoscopic transsphenoidal approach is the method preferred for surgically treating pituitary lesions in adults at our institution.

Transnasal Endoscopic Approach to the Sella Turcica

1998 ◽  
Vol 12 (4) ◽  
pp. 283-288 ◽  
Author(s):  
Michelle R. Aust ◽  
Thomas V. McCaffrey ◽  
John Atkinson
Keyword(s):  
Pituitary Gland ◽  
Pituitary Adenomas ◽  
Sphenoid Sinus ◽  
Sella Turcica ◽  
Cerebrospinal Fluid Leak ◽  
Pituitary Surgery ◽  
Endoscopic Approach ◽  
Transseptal Approach ◽  
Transnasal Endoscopic Approach ◽  
Posterior Septum

The transseptal/transsphenoidal approach to the pituitary gland has been the most commonly used approach for resection of pituitary adenomas for the last 50 years. This procedure has a low morbidity and provides direct midline access to the sella and pituitary gland. Recent advancements in endoscopic surgery, however, suggest that a lower morbidity approach to the sella would be possible via transnasal endoscopic route. Prior reports have confirmed effectiveness of this approach to the pituitary gland and we report here an early series of endoscopic transnasal pituitary surgery from our institution. We report seven cases of transnasal endoscopic pituitary surgery. Our technique consists of endoscopic exposure of the sphenoid ostium unilaterally, excision of the posterior septum anterior to the rostrum of the sphenoid sinus with resection of the sphenoid rostrum for bilateral exposure of the sphenoid sinus. A specially designed nasal speculum is positioned to displace the posterior septum and lateralize the middle turbinates, permitting direct midline exposure of the sphenoid sinus and sella. We have progressively modified the technique over the seven cases that we present and will discuss our specific instrumentation, indications, and technique for this procedure. We have encountered one cerebrospinal fluid leak in this series. Patient satisfaction has been high and hospitalization is less than with the conventional transseptal approach, averaging 1 day. Our impression is that the transnasal endoscopic approach to pituitary adenomas is a safe technique with reduced morbidity permitting shortened hospital stay.

scholarly journals Visual Improvement after Endoscopic Endonasal Transsphenoidal Excision of Pituitary Gland Tumor

2019 ◽  
Vol 23 (4) ◽  
Author(s):  
ZUBAIR AHMED KHAN ◽  
HABIB SULTAN ◽  
MUHAMMAD WAQAS ◽  
SARFRAZ KHAN ◽  
TOQEER AHMED ◽  
...  
Keyword(s):  
Visual Acuity ◽  
Pituitary Gland ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Gland Tumor ◽  
Endoscopic Endonasal ◽  
Age And Gender ◽  
Tumor Excision ◽  
Visual Improvement ◽  
And Gender

Objective: To evaluate the frequency of improved visual acuity after Endoscopic Endonasal Transsphenoidal excision of pituitary gland tumor.Study Design: Descriptive case series.Materials and Methods: In our study, Pre-operative visual acuity was noted by using the Snellen’s chart. Then patients underwent pituitary gland excision though Endoscopic Endonasal Transsphenoidal approach under general anesthesia. After surgery, patients were shifted in postsurgical wards and then will be discharged from there and were examinedfor 3 months in OPD. Snellen’s chart was used to evaluate patents for visual acuity after 3 months by an experienced ophthalmologist having at least 4 years residency experience If visual acuity increased ≥ 1 line, then improved visual acuity was labeled.Results: Improved visual acuity after pituitary gland tumor excision was seen in 59(89.39%) patients. Age and gender of patients did not show any statistically significant association for improved visual acuity.Conclusions: Results of this study showed that pituitary gland tumor excision through Endoscopic Endonasal Transsphenoidal approach is effective in terms of visual acuity improvement. Our main objectives in pituitary surgery are protection and reinstatement of vision and this surgical approach give maximum cover to vision restoration.

A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

2011 ◽  
Vol 114 (5) ◽  
pp. 1380-1385 ◽  
Author(s):  
Richard A. Chole ◽  
Chris Lim ◽  
Brian Dunham ◽  
Michael R. Chicoine ◽  
Ralph G. Dacey
Keyword(s):  
Transsphenoidal Surgery ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Surgical Approaches ◽  
Surgical Experience ◽  
Endoscopic Techniques ◽  
Minimally Invasive Surgical ◽  
Transsphenoidal Pituitary Surgery ◽  
Microscopic Techniques

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.

Hermann Schloffer and the origin of transsphenoidal pituitary surgery

2012 ◽  
Vol 33 (2) ◽  
pp. E5 ◽  
Author(s):  
Richard F. Schmidt ◽  
Osamah J. Choudhry ◽  
Ramya Takkellapati ◽  
Jean Anderson Eloy ◽  
William T. Couldwell ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Skull Base Surgery ◽  
Sella Turcica ◽  
Pituitary Surgery ◽  
Transsphenoidal Approach ◽  
Harvey Cushing ◽  
Transsphenoidal Pituitary Surgery ◽  
Transsphenoidal Operation ◽  
Technological Limitations ◽  
The University

A little over a century ago, in 1907, at the University of Innsbruck, Hermann Schloffer performed the first transsphenoidal surgery on a living patient harboring a pituitary adenoma. Schloffer used a superior nasal route via a transfacial lateral rhinotomy incision. This was perhaps his greatest academic contribution to neurosurgery. Despite the technological limitations of that time, Schloffer's operation was groundbreaking in that it laid the foundation for future development and refinement of transsphenoidal pituitary surgery, influencing prominent surgeons such as Oskar Hirsch and Harvey Cushing. Even after undergoing multiple modifications and a brief fall into obscurity, the transsphenoidal approach has endured through generations of surgeons and remains the preferred approach for lesions of the sella turcica to this day. Although Schloffer performed primarily abdominal surgery in his practice, his contributions to the transsphenoidal approach have had a lasting impact in the field of pituitary and skull base surgery. The authors review the life and career of Hermann Schloffer, the surgical details of his transsphenoidal operation, and the legacy that it has left on the field of pituitary surgery.

scholarly journals Metastatic Mantle Cell Lymphoma to the Pituitary Gland: Case Report and Literature Review

2016 ◽  
Vol 9 (1) ◽  
pp. 25-32 ◽  
Author(s):  
Arthur Wang ◽  
Nathan Carberry ◽  
Elena Solli ◽  
George Kleinman ◽  
Adesh Tandon
Keyword(s):  
Pituitary Gland ◽  
Mantle Cell Lymphoma ◽  
Cell Lymphoma ◽  
Sella Turcica ◽  
Pituitary Tumors ◽  
Surgical Excision ◽  
Gastrointestinal Carcinoma ◽  
Metastatic Lesions ◽  
Mantle Cell ◽  
History Of

We present an unusual case of a metastatic mantle cell lymphoma (MCL) to the pituitary gland. The patient had a known history of MCL for which she previously received chemotherapy. She presented with new-onset diplopia and confusion, and reported a history of progressive vision blurriness associated with headache, nausea, and vomiting. MRI of the brain showed an enhancing lesion within the sella turcica involving the cavernous sinuses bilaterally, extending into Meckel's cave on the left, and abutting the optic nerves bilaterally. Following surgical excision, histopathology revealed the tumor to be a MCL. Metastatic pituitary tumors are rare and have been estimated to make up 1% of tumors discovered in the sellar region. The two most common secondary metastatic lesions to the sella are breast and lung carcinoma followed by prostate, renal cell, and gastrointestinal carcinoma. Metastatic lymphoma to the pituitary gland is especially rare and is estimated to constitute 0.5% of all metastatic tumors to the sella turcica. To our knowledge, this is the first reported case of MCL metastasizing to the pituitary gland.

Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors

2006 ◽  
Vol 104 (1) ◽  
pp. 7-19 ◽  
Author(s):  
Edward H. Oldfield ◽  
Alexander O. Vortmeyer
Keyword(s):  
Pituitary Gland ◽  
Surgical Techniques ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Surrounding Tissue ◽  
Maximum Diameter ◽  
Preoperative Imaging ◽  
Tumor Diameter ◽  
Cushing Disease ◽  
Pituitary Glands

Object The presence of a histological pseudocapsule around pituitary tumors was noted in the early 1900s. Since that time there has been no emphasis on the sequence of the stages of its development or on the relationship between these stages and the capacity to identify very small pituitary tumors at surgery in patients in whom preoperative imaging has been nondiagnostic. In addition, limited emphasis has been given to the pseudocapsule’s use for selective and complete resection of pituitary adenomas. Methods The development of the pseudocapsule was examined by performing histological analysis of portions of pituitary glands removed during 805 operations for Cushing disease. Twenty-five adenomas, each measuring between 0.25 and 4 mm in maximum diameter, were detected in the excised specimens; 17 were adenocorticotropic hormone–positive adenomas and eight were incidental tumors (four prolactin-secreting and four nonsecreting lesions). In 16 tumors the size of the adenoma could be established. The distribution of tumor size in relation to the presence of a histological pseudocapsule indicates a transition from the absence of a reticulin capsule (tumor diameter ≤ 1 mm) through the initial compression of surrounding tissue (tumor diameter 1–2 mm) to the presence of a multilayered reticulin capsule observed when adenomas become larger (tumor diameter 2–3 mm). Conclusions The absence of a reticulin capsule in cases of very small tumors may contribute to limited localization of these lesions during surgical exploration of the pituitary gland. In this article the authors describe surgical techniques in which the histological pseudocapsule is used as a surgical capsule during pituitary surgery. In their experience, recognition of this surgical capsule and its use at surgery has contributed to the identification of microadenomas buried in the pituitary gland, aided the recognition of subtle invasion of the pituitary capsule and contiguous dura mater, and enhanced the consistency of complete tumor excision with small and large tumors.

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