Page 1 of 6 Review Microscopic endonasal access in pituitary surgery for tumour removal: eight-year review of nasal complications H Raja 1 *, T Upile 2 , W Jerjes 3 , N Charakias 4 , V Dewan 5 , RM Redfern 6 Abstract leaks or meningitis. Unfortu nately, a retrospective study of complica - one patient succumbed from the con- tions associated with this procedure Introduction sequences of internal carotid artery was undertaken. Trans-sphenoidal pituitary resection damage. Access to the pituitary gland had is possible via the traditional micro- Conclusion been microscopic and via the trans- scopic trans-septal approach or newer Nasal complication rates from this septal route following the work of endoscopic transnasal approach. There method were low. A microscope can Hardy in the 1960s and 1970s 2,3 . In is little in the literature to describe All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. be successfully used in an endonasal recent years, however, the endoscope the nasal complications of the endona- approach to the sella on its own. It has started to establish itself as the sal microscopic resection of pituitary can also be a useful adjunct to the option of choice because of improved lesions. We describe our experience of endoscope and this skill should not visualisation offered to the operating a single surgeon series and specifi- be forgotten by ear, nose and throat surgeon and excellent short-term re- cally the nasal complications from surgeons and neurosurgeons. It ap- sults. However, long-term resection this method. pears that the method of approaching results of this technique are still Method the sella (transnasal vs trans-septal) awaited. Nevertheless, it carries a We preformed an 8-year retrospec- rather than the instrument used tive case notes review of transnasal helps to determine the rate of nasal endoscopic resections of 70 pituitary complications. tumours. The data were collected on a proforma developed after consulta - Introduction tion with a multidisciplinary team There have been many advances in and validated independently by ran- approaches to the pituitary gland dom interval analysis. over the past century. Having been Results first performed transcranially 1 , when- Gross tumour removal rate was All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure. ever the anatomical configuration of achieved in 77.1% (n = 54/70) cases the condition allows, the preferred by 24 months follow-up. One patient approach for lesions of the sella is experienced a purulent nasal dis- trans-sphenoidal (Figure 1). Access charge, which required antibiotic to the sphenoid sinus has generally intervention, whilst another had per- Competjng interests: none declared. Confmict of interests: none declared. been performed using a midline sub- sistent maxillary nerve damage with mucosal resection. This trans-septal Figure 1: Clinico-pathological image paraesthesia. No patient experienced route uses either a sublabial ap- showing the volume effect and loca- persistent epistaxis, septal perfora- proach to the septum or an incision tion of a pituitary tumour. Note its tion, anosmia, cerebrospinal fluid in the mucosa commencing within intimate relationship to the sphenoid the anterior nares; both techniques and basisphenoid region of the skull * Corresponding author usually involve resection of at least base. Also note the short distance to Email: hemalraja@yahoo.co.uk part of the nasal septum. Further- the cribiform plate and the superior 1 Department of ENT, University Hospital more, even in experienced hands, the aspect of the internal nasal anatomy Birmingham, UK incidence of nasal septum perfora - indicating that transnasal approaches 2 Department of Otolaryngology, Bielefeld tion is reported to be 3.3%. A direct may have utility in the removal of University, Germany 3 Leeds Institute of Molecular Medicine, transnasal approach to the sphenoid these types of lesions. In addition, the University of Leeds, UK sinus avoids potential complications circumscribed nature of the tumour 4 Department of ENT, Lancashire Teaching of submucosal resection and, in case and its intimate relationship to the Hospitals, UK 5 Department of Anatomy, University of of a translabial approach, removal of location of the path of the internal ca- Birmingham, UK the maxillary spine. To assess the ben- rotid arteries and optic chiasma can 6 Department of Neurosurgery, Morriston efits of the direct transnasal approach, be appreciated. Hospital, UK Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY) For citation purposes: Raja H, Upile T, Jerjes W, Charakias N, Dewan V, Redfern RM . Microscopic endonasal access in pituitary surgery for tumour removal: eight-year review of nasal complications. Head Neck Oncol. 2012 Nov 23;4(4):76.
Page 2 of 6 Review clear advantage in the published data In many cases, computed tomogra- betadine solution and the right thigh thus far over the microscopic trans- phy (CT) imaging was also available. was prepared, in expectation should septal technique, with equivalent or In addition to providing confirmation a fascia lata graft be required. Surgery better results and fewer complica- that a trans-sphenoidal approach was undertaken via the right anterior tions 4 . However, majority of the com- was appropriate, the coronal images nares in all cases using the operating parative studies have not compared (MRI or CT) were used to define microscope and with lateral screen- endoscopic transnasal technique the position and characteristics of the ing using an image intensifier with microscopic transnasal tech- sphenoid septum, an essential land- (Figures 5–7). The sphenoid sinus nique, as the endoscopic technique mark in establishing the position of the was approached via a direct transna- has its own disadvantages. midline pre-operatively. Cefuroxime sal approach. Any nasal polyps en- Both techniques usually involve re- (1.5 g) was intravenously adminis- countered were reduced using section of at least part of the nasal tered routinely with induction, to- bipolar coagulation or microdebrider. septum. Trauma to the nose and sub- gether with hydrocortisone (100 mg). After coagulating the nasal mucosa sequent complications can form a Once positioned on the operating overlying the right side of the vomer, significant basis of morbidity for pa- table, the anterior nasal mucosa of a posterior right septotomy ± pos- All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. tients undergoing pituitary surgery. both nostrils was liberally coated terior septectomy was performed. They may not be perceived as being with benzoylmethylecgonine paste. as important as other life-threatening The face was prepared using aqueous complications of sellar and parasellar regions, but they can leave the pa- tients with symptoms that often will require ear, nose and throat (ENT) input. Even in experienced hands, the incidence of nasal septum perfo- ration is reported to be 3.3% 5 . We present our retrospective series of the complications experienced by the direct transnasal microscopic ap- proach with no endoscopic assis- tance. This is the largest case series Figure 2: An image of a pathology of its kind in Europe and the fifth slide stained with haematoxylin and largest overall. All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure. Figure 4: An intraoperative screen- eosin and immunostains showing a ing plain X-ray image within a se- somatotrophinoma. Methods and materials quence showing the localisation hook All patients presenting with pituitary advanced into the region of the pitui- tumours (Figure 2) were managed in tary fossa. a multidisciplinary environment with Competjng interests: none declared. Confmict of interests: none declared. teams including neuroendocrinology specialists with a neurosurgeon and two endocrinologists, supported by Departments of Neuropathology, Neuroradiology and Ophthalmology. The records of 70 consecutive pa- tients undergoing pituitary surgery via the transnasal route by a single surgeon during the preceding 8 years were obtained. There were 42 males and 28 females. The mean age was 56 years (range, 19–85 years). There were 66 pituitary adenomas, 3 cra- Figure 3: An intraoperative screen- niopharyngiomas and 1 meningioma. ing plain X-ray image within a se- Figure 5: An intraoperative screen- Pre-operative imaging included quence showing a localisation hook ing plain X-ray image within a se- coronal magnetic resonance imaging introduced via the nasal cavity and quence showing the localisation hook (MRI) in all cases (Figures 3 and 4). into the sphenoid paranasal sinus. retracted from the pituitary fossa. Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY) For citation purposes: Raja H, Upile T, Jerjes W, Charakias N, Dewan V, Redfern RM . Microscopic endonasal access in pituitary surgery for tumour removal: eight-year review of nasal complications. Head Neck Oncol. 2012 Nov 23;4(4):76.
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