- Email: [email protected]
Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: Assessment of technique and postoperative findings of nasal and paranasal cavities
Auris Nasus Larynx 34 (2007) 57–63 www.elsevier.com/locate/anl
Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: Assessment of technique and postoperative findings of nasal and paranasal cavities Shinichi Haruna a,*, Nobuyoshi Otori b, Hiroshi Moriyama b, Masami Kamio c a
Department of Otolaryngology, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu-machi, Tochigi 321-0293, Japan b Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan c Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan Received 13 December 2005; accepted 15 September 2006 Available online 1 December 2006
Abstract Objective: Transnasal endoscopic surgery is the most common approach to removal of pituitary tumors. This study evaluated the transnasal transethmosphenoidal approach (TTES) in terms of its operative manipulability and the postoperative status of the paranasal cavities. Methods: A total of 132 patients with pituitary tumors underwent surgery by one of the following three approaches: (1) bilateral TTES, in which the surgical procedures were performed via the bilateral paranasal cavities, (2) unilateral TTES, in which the procedures were performed via one side only, and (3) unilateral TTES and resection of the posterior portion in the nasal septum approach (RPS), which is a modification of approach (2) and enables performance of the procedures from both sides. Results: The degree of freedom for the surgical procedures with each of the approaches decreased in the following order: bilateral TTES, unilateral TTES and RPS, and unilateral TTES. The postoperative CT images and endoscopic findings were good with each of the surgical approaches, but the incidences of olfactory disturbance and nasal dryness were significantly higher with the bilateral TTES compared with the unilateral TTES and RPS and the unilateral TTES. Conclusion: The unilateral TTES and RPS was for us most suitable approach of the three methods. In the case of advanced tumors, the bilateral TTES should be selected because it permits superior operative manipulability. Finally, the unilateral TTES is most appropriate for removal of tumors that are deviated to one side and localized within the sella. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Endoscopic pituitary surgery; Transnasal transethmosphenoidal approach; Assessment of technique; Postoperative findings of nasal and paranasal cavities
1. Introduction Recent years have seen a shift in the surgical technique for pituitary tumors from the traditional microscopic method [1] to endoscopic surgery via a transnasal approach. In comparison with the microscopic method, endoscopic surgery is considered to be highly useful since it affords a brighter and broader field of view, allows the tumor to be precisely resected and also results in fewer complications and thus greater safety [2–4]. The endonasal approach is * Corresponding author. Tel.: +81 282 87 2164; fax: +81 282 86 5928. E-mail address: [email protected] (S. Haruna).
made through one nostril, and the space from the olfactory cleavage to the vicinity of the natural ostium of the sphenoidal sinus is broadly opened, the sphenoidal septum is resected, and the bilateral sphenoidal sinuses are made into a single sinus. In this approach, the manipulations of the endoscope and forceps are performed from this single sinus to accomplish the surgery. Generally, during the pituitary surgery, the operation field is easily bleeding and both hand surgery is necessary to take the tumor. Furthermore, in case of the endonasal endoscopic pituitary surgery, the frocept, suction tube and one rigid endoscopy are needed to be inserted through one or two nostrils. A lateral luxation of the middle turbinate [5] or
0385-8146/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2006.09.019
58
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
resection of the middle conchoa with curved chisels [6] were reported to obtain the widen space between the middle turbinate and nasal septum. We earlier reported on the usefulness of a bilateral transnasal transethmosphenoidal approach (bilateral TTES) with anterior and posterior ethomoidectomy when performing endoscopic sinus surgery for chronic sinusitis [7]. The middle and superior turbinate can be easily lateralized after anterior and posterior ethmoid sinus are opened, and a working space in the olfactory cleft will become much wider during the pituitary surgery. Although the radical treatment for sinus is increased, the operator can easily and widely observe the sphenoid sinus and pituitary tumor and more safely treat the pituitary tumor of the any type. At the end of operation, the turbinate is replaced to avoid morphological abnormalities of the nasal cavities. Thomas RF et al reported removal of the ethmoid sinus might place the patients at no risk for bleeding or infection though the nasal packing must be inserted in our hospital [8]. However, the state of the paranasal cavity is nearly normal in a majority of patients with a pituitary tumor, and there is a possibility that some sort of postoperative paranasal functional disorder will develop [3]. Accordingly, the present study was carried out to assess the state of the nasal and paranasal cavities after each of the three TTES approaches and with the objective of identifying a less invasive approach to the paranasal cavity.
2. Methods 2.1. Subjects The subjects of this study were 132 patients who had undergone endoscopic TTES surgery for pituitary tumors during the period from 1995 through 2004. The surgery was the initial procedure for 100 of those patients, whereas the remaining 32 patients had undergone previous surgery. The age range was 26–72 years (mean: 54.3 years), and the male to female ratio was 89:43. The diagnoses consisted of 68 cases of nonfunctional adenoma, 21 cases of GH-secreting adenoma, 16 cases of ACTH-secreting adenoma, 14 cases of prolactinoma, 8 cases of Rathke cyst and 5 miscellaneous cases. Five patients also had chronic sinusitis with a nasal polyp, and they first underwent endoscopic sinus surgery (ESS), and then, after the sinusitis had subsided they underwent a second operation via the same route to resect the pituitary tumor. Sagittal section MRI images were taken, and the pituitary tumors were classified into four categories, i.e., small, intrasellar, suprasellar or invasive type, on the basis of the findings regarding their size and location relative to the sella turcica. The results were as follows: 17 small cases, 52 intrasellar cases, 57 supersellar cases and 6 invasive type cases.
The chief complaints consisted of visual disorders in 90 patients (68 nonfunctional adenomas, 5 GH-secreting adenomas, 8 Rathke cysts, 4 prolactinomas and 5 miscellaneous) and hormone production abnormalities in 42 patients (16 GH-secreting adenomas, 16 ACTH-secreting adenomas and 10 prolactinomas). 2.2. Surgical technique Three different TTES approaches with anterior and posterior ethmoidectomy have been used to carry out the operative procedures (Fig. 1). They were: (1) a bilateral transnasal transethmosphenoidal approach (bilateral TTES), in which the bilateral ethmoidal and sphenoidal sinuses are opened, an endoscope is inserted into one nostril, and clamping and suction are performed via both sides; (2) a unilateral TTES approach, in which the ethmoidal and sphenoidal sinuses are completely opened on only one side, and insertion of the endoscope and the surgical procedures are performed via that side; and (3) an approach consisting of unilateral TTES and extensive resection of the posterior portion of the nasal septum, with the endoscope inserted along the olfactory cleft on the contralateral side and with the procedures performed bimanually via the opened side (unilateral TTES and RPS). After the nasal and paranasal cavity surgeries in approaches (1) and (3), a 08 or 308, 4-mm rigid endoscope was immobilized in one nostril using a retaining device (Storz1, Germany). In addition, an endoscope cleaning device (Endoscrub, Xomed1; USA) was attached to prevent clouding of the endoscope due to blood. A navigation system (Insta Track Visualization Technology Inc.1; USA) was used to identify the location of the tumor and the juxtapositions of the vital organs. At this point, a neurosurgeon took over and performed the resection of the pituitary tumor like. After the tumor had been almost eliminated, the endoscope was freed from its retainet and inserted into the sella turcica, and the residual tumor tissue was extirpated while being viewed. bone filler (APACERAM1 Pentax; Japan) was immobilized at the site of the bone defect in the posterior wall of the sphenoidal sinus with bone cement. In the case of spinal fluid leakage during the operation, fascia and fatty tissue were harvested from the thigh, and the sella was packed with the fatty tissue and covered with the fascia lata, immobilized with bone cement. Gauze nasal packing (Vesukitin1; Japan) was inserted into the nasal and paranasal cavities, completing the surgery. It was anticipated that the patients would be discharged from the hospital in the absence of postoperative complications such as spinal fluid leakage, etc. after removing gauze packing. Macrolide therapy was administered for 2–3 months after the operation to promote epithelization of the paranasal sinus mucosa [9]. All of the patients were operated on by the same ENT doctor and neurosurgeon.
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
59
Fig. 1. The three endoscopic transnasal transethmoidal surgery (TTES) approaches. In the bilateral TTES approach, the bilateral ethmoidal and sphenoidal sinuses are opened and the middle and superior turbinate were shift to the lateral wall in order to keep the working space and facilitate the surgical procedures, but at the end of operation the middle and superior turbinate were replaced to the original portion. An endoscope is immobilized in one nostril, and the surgery is performed via the bilateral nasal cavities using both hands. In the unilateral TTES approach, the ethmoidal and sphenoidal sinuses are opened on only one side, an endoscope is put in place, and the surgery is performed using only one hand. In the unilateral TTES and RPS approach, the ethmoidal and sphenoidal sinuses are opened on only one side, the posterior portion of the nasal septum is extensively resected, an endoscope is inserted via the contralateral, unopened side, and the surgery is performed via the opened side using both hands.
2.3. Nasal symptom score
2.6. Statistical analysis
After at least 1 year had passed since the operation, the patient assessed his/her symptoms on a visual analog scale (VAS) using scores of 0–10, where ‘‘0’’ means no symptoms are present and ‘‘10’’ means severe symptoms are present. This method was applied to nasal obstruction, nasal discharge, headache, olfactory disturbances, nasal dryness and overall symptomatic assessment [10].
Statistical significance was performed by nonparametric Mann–Whitney’s U-test because the groups were unmatched. A p value of less than 0.05 was considered statistically significant. All statistical analyses were performed on a personal computer with the statistical package SPSS for Windows (Version 11.0, SPSS, Chicago, IL). 2.7. Informed consent
2.4. CT scan assessment After at least 1 year had passed since the operation, The CT images were subjected to radiological grading using the Lund stage classifications [10]. Each sinus was graded between 0 and 2 (0: no abnormality; 1: partial opacification; 2: total opacification). The total scores for the four left and right paranasal sinuses (anterior and posterior ethmoid, maxillary sinus, frontal sinus, sphenoid sinus) are shown. 2.5. Postoperative endoscopic findings After at least 1 year had passed since the operation, the endoscopic findings for the sphenoidal sinus were assessed as either well healed or abnormal (i.e., mucosal hypertrophy, inflammation, discharge, crusting, middle meatus adhesions and polyposis) [11].
The study was approved by the ethics committee of the Jikei University School of Medicine and was performed with the informed consent of each of the patients. 3. Results 3.1. Surgical procedures The patients consisted of 72 who underwent bilateral TTES, 54 who underwent unilateral TTES and RPN and 6 patients who underwent unilateral TTES. In the patients who were undergoing repeated surgery, the approach was microscopic transseptal transphenoidal surgery in 30 patients and unilateral TTES and bilateral TTES in one patient each. The bilateral TTES approach was the more flexible method and particularly effective for advanced tumors that
60
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
were suprasellar or invasive. On the other hand, the unilateral TTES approach resulted in a limited degree of freedom for the manipulation of the forceps since the forceps, suction tube and endoscope were all inserted via the same nostril. In 12 patients, the unilateral TTES approach was initially selected, but manipulation of the forceps proved difficult because of the advanced state of the tumor or copious bleeding; thus, the approach was changed to the bilateral TTES approach in 4 patients and to the unilateral TTES and RPS approach in the other 8 patients. Especially in cases of ACTH-secreting adenomas, although the tumor was small in size, the surgical procedures were complicated by bleeding, and the ability to use both hands proved to be effective. Comparison of the size of the tumor and the surgical approach revealed that the small tumors were removed by the bilateral TTES approach in one patient and by the unilateral TTES and RPS approach in 16 patients, whereas the unilateral TTES approach was not selected for any patients. For the intrasellar tumors, the approach was bilateral TTES in 26 patients, unilateral TTES and RPS in 20 patients and unilateral TTES in 6 patients. The suprasellar tumors were removed by the bilateral TTES approach in 39 patients and by the unilateral TTES and RPS approach in 18 patients, while the unilateral TTES approach was not selected for any patients. All cases of invasive pituitary tumor were treated by the bilateral TTES approach. In patients who were undergoing repeated surgery, the same route was employed in the case of the bilateral TTES approach, whereas patients who had previously undergone the unilateral TTES approach were changed to the unilateral TTES and RPS approach for the second operation. Regarding the result of the operation, total removal of the tumor was achieved in all of the patients with a small tumor. In the total of 52 patients with an intrasellar tumor, the results showed total removal in 42 patients and subtotal removal in 10 patients. For the 57 patients with suprasellar tumors, the surgery achieved total removal in 18 patients, subtotal removal in 37 patients and partial removal in
6 patients. Only partial removal was achieved in all of the patients with invasive type pituitary tumors. 3.2. CT images Postoperative CT scans of the paranasal cavities showed partial opacification in all of the patients. There were no findings indicative of total opacification or development of a mucocele. Three of the patients for whom the bilateral TTES approach was selected and two patients who underwent the unilateral TTES and RPS approach had had chronic sinusitis prior to the surgery, and the surgery was thus performed in two stages for those patients. Overall, the incidence of abnormal radiological findings for the paranasal sinuses was very small with each of the approaches, and no statistically significant differences existed among them (Fig. 2). 3.3. Postoperative nasal symptoms All three surgical approaches showed low scores for each of the nasal symptom categories of nasal obstruction, nasal discharge and headache. However, the scores for olfactory disturbances and nasal dryness were significantly higher with the bilateral TTES approach compared with the unilateral TTES and RPS approach and the unilateral TTES approach ( p < 0.05). With regard to the overall document, as well, the score was higher with the bilateral TTES approach compared with both the unilateral TTES and RPS approach and the unilateral TTES approach, but without statistical significance (Fig. 3). 3.4. Overall postoperative findings for the ethmoidal and sphenoidal sinuses The ratios of well-healed sinuses following the surgery by the bilateral TTES approach, the unilateral TTES and RPS approach and the unilateral TTES approach revealed very good results: 132/144 (92.6%), 47/54 (87.0%) and 6/6
Fig. 2. Postoperative CT images for the unilateral TTES and RPS approach. The right ethmoidal sinuses were opened, and the posterior portion of the nasal septum was resected. The images show the APACERAM1 bone filler that was used to create a floor for the sella.
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
61
Fig. 3. Comparison of the nasal symptoms with each TTES approach. The plots show, from the top, the values for the 10th, 25th, 50th, 75th and 90th percentiles. There were no statistically significant differences among the three TTES approaches with regard to the postoperative incidences of nasal obstruction, nasal discharge or headache. However, the incidences of olfactory disturbances and nasal dryness were significantly higher with the bilateral TTES approach than with the unilateral TTES approach ( p < 0.05).
(100%), respectively (Fig. 4 and Table 1). The most common abnormal findings consisted of pus discharge in the sphenoidal sinuses, partial adhesion of the middle meatus and partial adhesion of the olfactory cleft. Improvement of
the infection in the sphenoidal sinuses was achieved by flushing with physiological saline solution and administration of antibiotics. Also, the adhesions of the middle meatus and olfactory cleft were later surgically freed. A nasal
Fig. 4. Postoperative endoscopic nasal findings with the unilateral TTES and RPS approach. The right ethmoidal sinuses were opened (upper right), and the mucosa of the ethmoidal and sphenoidal sinuses is seen to be good. The APACERAM1 bone filler that was used to create a floor for the sella can be seen (*).
62
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
Table 1 Postoperative endoscopic findings for the ethmoidal and sphenoidal sinuses
With each of the three TTES approaches, the mucosal lining was observed to be well healed in about 90% of the patients. There were more cases of partial adhesion of the middle meatus or olfactory cleft in the patients operated upon by the bilateral TTES approach and the unilateral TTES and RPS approach. * Healthy mucosal lining and with no evidence of inflammation, mucosal swelling, hypertrophy, polyposis or scarring.
septum perforation was noted in 21 of 30 patients who had previously undergone microscopic transseptal transsphenoidal surgery, but this abnormality was not observed after switching the surgical technique to the TTES approach. 3.5. Complications Spinal fluid leakage occurred immediately after the surgery in a total of seven patients, consisting of five patients with suprasellar disease and two patients with invasive disease. Within several days the leakage site was repaired via the same operative route in each of these patients by using fatty tissue and fascia that had been harvested from the thigh area.
4. Discussion A middle meatus approach for pituitary tumor is reported to be seldom used excepted as a straight approach to the ipsilateral cavernous sinu [12]. Although our approach is similar to the above the middle meatus approach at the point of opening both the ethmoidal and sphenoidal sinuses, the TTES approach not only create a sufficient working space for removal of the tumor by shifting the middle and superior turbinate to the lateral wall, but also during the surgery prevent occlusion of the OMC due to displacement of the medial wall of the nasal cavity – especially the nasal turbinate bones – caused by the surgical tools or endoscope [7]. After application of the bilateral TTES approach, the paranasal sinuses were confirmed to show good epithelization in 92.6% of the patients, and postoperative CT images also did not reveal any problematic sinusitis. However, comparison of the postoperative nasal symptoms between the unilateral TTES approach and the bilateral TTES approach showed that nasal obstruction, nasal discharge and headache did not represent significant problems with either approach, whereas the numbers of patients complaining of
olfactory disturbances and nasal dryness were statistically increased in the case of the bilateral TTES approach. Therefore, with the objective of reducing the invasiveness to the paranasal sinuses, we introduced the unilateral TTES and PRS approach. With this unilateral TTES and PRS approach, we have been able to reduce the incidences of postoperative olfactory disturbances and nasal dryness to about the same as with the unilateral TTES approach. With all three of the surgical approaches analyzed in this report, about 90% of the endoscopic images of the postoperative paranasal sinuses were rated as well healed. The bilateral TTES approach patients and the unilateral TTES and PRS approach patients showed high incidences of partial adhesion of the middle meatus and the olfactory cleft, but none of these cases aggravated to the point of formation of a mucocele. In the CT images, as well, the incidence of abnormal shadows in each of the paranasal sinuses was within 3%, and the overall results indicated good epithelization of the paranasal sinus mucosa. In endoscopic surgery for pituitary tumors accompanied by bleeding, the selection of the surgical approach must be based on consideration of not just the size and the degree of progression of the tumor, but also the extent of bleeding in the operative field. When the amount of bleeding is large, surgical manipulations with only one hand become difficult. For the present patient series, the unilateral TTES approach was initially selected for small tumors, but bimanual manipulation is necessary in the event of bleeding at the time of extirpation of the tumor, and for this reason we have more recently switched to the bilateral TTES approach or the unilateral TTES and PRS approach for such small adenomas. Overall consideration of the surgical manipulability and the postoperative complications and nasal symptoms leads us to surmise that the unilateral TTES and PRS approach is for us the most suitable technique, and that the bilateral TTES approach is best suited for large, advanced tumors because of the high degree of freedom it affords for the
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
surgical manipulations. On the other hand, in the case of the unilateral TTES approach it is difficult to perform the resection of tumors that have advanced to the contralateral side. In addition, since the endoscope, forceps and suction tube are all inserted into the same paranasal sinus, these tools bump into each other and the surgical procedures are difficult to execute. Therefore, we think that the unilateral TTES approach is most appropriate for removal of tumors that are deviated to one side and localized within the sella. In conclusion, for performance of endoscopic surgery on pituitary tumors that are accompanied by bleeding in the operative field, the surgical approach should be selected in order to secure the visual field and surgical manipulability that will be needed in consideration of the degree of progression of the tumor and its location. In addition, it is important to select an approach that is minimally invasive to the paranasal sinuses.
References [1] Hardy J. Transsphenoidal microsurgery of the normal and pathological puitary. Clin Neurosurg 1969;16:185–217.
63
[2] Sethi DS, Leonf JL. Endoscopic pituitary surgery. Otolaryngol Clin North Am 2006;39:563–83. [3] White DR, Sonnenburg RE, Ewend MG, Senior BA. Safety of minimally invasive pituitary surgery (MIPS) compared with a traditional approach. Laryngoscope 2004;114:1945–8. [4] Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 1997;87:44–51. [5] Cappabianca P. Endoscopic endonasal transspenoidal surgery. Neurosurgery 2004;55:933–41. [6] Jankowski R. Endoscopic pituitary surgery. Larngoscope 1992;102:198–202. [7] Otori N, Haruna S, Kamio M, Ohashi G, Moriyama H. Endoscopic transethomoidal approach for pituitary tumors with image guidance. Am J Rhinol 2001;15(6):381–6. [8] Thomas RF, Monacci WT, Mair EA. Endoscopic image-guided transethmoid pituitary surgery. Otolaryngol Head Neck Surg 2002;127:409–16. [9] Moriyama H, Yanagi K, Ohtori N, Fukami M. Evaluation of endoscopic sinus surgery for chronic sinusitis: post-operative erythromycin therapy. Rhinology 1995;33(3):166–70. [10] Valerie JL, Ian SM. Staging in rhinosinusitis. Rhinology 1993;31:183– 4. [11] Kennedy DW. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 1992;102(Suppl 57):1–18. [12] Jho HD, Affieri. Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition. Br J Neurosurg 2000;14(5):432–40.
Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: Assessment of technique and postoperative findings of nasal and paranasal cavities Shinichi Haruna a,*, Nobuyoshi Otori b, Hiroshi Moriyama b, Masami Kamio c a
Department of Otolaryngology, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu-machi, Tochigi 321-0293, Japan b Department of Otolaryngology, The Jikei University School of Medicine, Tokyo, Japan c Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan Received 13 December 2005; accepted 15 September 2006 Available online 1 December 2006
Abstract Objective: Transnasal endoscopic surgery is the most common approach to removal of pituitary tumors. This study evaluated the transnasal transethmosphenoidal approach (TTES) in terms of its operative manipulability and the postoperative status of the paranasal cavities. Methods: A total of 132 patients with pituitary tumors underwent surgery by one of the following three approaches: (1) bilateral TTES, in which the surgical procedures were performed via the bilateral paranasal cavities, (2) unilateral TTES, in which the procedures were performed via one side only, and (3) unilateral TTES and resection of the posterior portion in the nasal septum approach (RPS), which is a modification of approach (2) and enables performance of the procedures from both sides. Results: The degree of freedom for the surgical procedures with each of the approaches decreased in the following order: bilateral TTES, unilateral TTES and RPS, and unilateral TTES. The postoperative CT images and endoscopic findings were good with each of the surgical approaches, but the incidences of olfactory disturbance and nasal dryness were significantly higher with the bilateral TTES compared with the unilateral TTES and RPS and the unilateral TTES. Conclusion: The unilateral TTES and RPS was for us most suitable approach of the three methods. In the case of advanced tumors, the bilateral TTES should be selected because it permits superior operative manipulability. Finally, the unilateral TTES is most appropriate for removal of tumors that are deviated to one side and localized within the sella. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Endoscopic pituitary surgery; Transnasal transethmosphenoidal approach; Assessment of technique; Postoperative findings of nasal and paranasal cavities
1. Introduction Recent years have seen a shift in the surgical technique for pituitary tumors from the traditional microscopic method [1] to endoscopic surgery via a transnasal approach. In comparison with the microscopic method, endoscopic surgery is considered to be highly useful since it affords a brighter and broader field of view, allows the tumor to be precisely resected and also results in fewer complications and thus greater safety [2–4]. The endonasal approach is * Corresponding author. Tel.: +81 282 87 2164; fax: +81 282 86 5928. E-mail address: [email protected] (S. Haruna).
made through one nostril, and the space from the olfactory cleavage to the vicinity of the natural ostium of the sphenoidal sinus is broadly opened, the sphenoidal septum is resected, and the bilateral sphenoidal sinuses are made into a single sinus. In this approach, the manipulations of the endoscope and forceps are performed from this single sinus to accomplish the surgery. Generally, during the pituitary surgery, the operation field is easily bleeding and both hand surgery is necessary to take the tumor. Furthermore, in case of the endonasal endoscopic pituitary surgery, the frocept, suction tube and one rigid endoscopy are needed to be inserted through one or two nostrils. A lateral luxation of the middle turbinate [5] or
0385-8146/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2006.09.019
58
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
resection of the middle conchoa with curved chisels [6] were reported to obtain the widen space between the middle turbinate and nasal septum. We earlier reported on the usefulness of a bilateral transnasal transethmosphenoidal approach (bilateral TTES) with anterior and posterior ethomoidectomy when performing endoscopic sinus surgery for chronic sinusitis [7]. The middle and superior turbinate can be easily lateralized after anterior and posterior ethmoid sinus are opened, and a working space in the olfactory cleft will become much wider during the pituitary surgery. Although the radical treatment for sinus is increased, the operator can easily and widely observe the sphenoid sinus and pituitary tumor and more safely treat the pituitary tumor of the any type. At the end of operation, the turbinate is replaced to avoid morphological abnormalities of the nasal cavities. Thomas RF et al reported removal of the ethmoid sinus might place the patients at no risk for bleeding or infection though the nasal packing must be inserted in our hospital [8]. However, the state of the paranasal cavity is nearly normal in a majority of patients with a pituitary tumor, and there is a possibility that some sort of postoperative paranasal functional disorder will develop [3]. Accordingly, the present study was carried out to assess the state of the nasal and paranasal cavities after each of the three TTES approaches and with the objective of identifying a less invasive approach to the paranasal cavity.
2. Methods 2.1. Subjects The subjects of this study were 132 patients who had undergone endoscopic TTES surgery for pituitary tumors during the period from 1995 through 2004. The surgery was the initial procedure for 100 of those patients, whereas the remaining 32 patients had undergone previous surgery. The age range was 26–72 years (mean: 54.3 years), and the male to female ratio was 89:43. The diagnoses consisted of 68 cases of nonfunctional adenoma, 21 cases of GH-secreting adenoma, 16 cases of ACTH-secreting adenoma, 14 cases of prolactinoma, 8 cases of Rathke cyst and 5 miscellaneous cases. Five patients also had chronic sinusitis with a nasal polyp, and they first underwent endoscopic sinus surgery (ESS), and then, after the sinusitis had subsided they underwent a second operation via the same route to resect the pituitary tumor. Sagittal section MRI images were taken, and the pituitary tumors were classified into four categories, i.e., small, intrasellar, suprasellar or invasive type, on the basis of the findings regarding their size and location relative to the sella turcica. The results were as follows: 17 small cases, 52 intrasellar cases, 57 supersellar cases and 6 invasive type cases.
The chief complaints consisted of visual disorders in 90 patients (68 nonfunctional adenomas, 5 GH-secreting adenomas, 8 Rathke cysts, 4 prolactinomas and 5 miscellaneous) and hormone production abnormalities in 42 patients (16 GH-secreting adenomas, 16 ACTH-secreting adenomas and 10 prolactinomas). 2.2. Surgical technique Three different TTES approaches with anterior and posterior ethmoidectomy have been used to carry out the operative procedures (Fig. 1). They were: (1) a bilateral transnasal transethmosphenoidal approach (bilateral TTES), in which the bilateral ethmoidal and sphenoidal sinuses are opened, an endoscope is inserted into one nostril, and clamping and suction are performed via both sides; (2) a unilateral TTES approach, in which the ethmoidal and sphenoidal sinuses are completely opened on only one side, and insertion of the endoscope and the surgical procedures are performed via that side; and (3) an approach consisting of unilateral TTES and extensive resection of the posterior portion of the nasal septum, with the endoscope inserted along the olfactory cleft on the contralateral side and with the procedures performed bimanually via the opened side (unilateral TTES and RPS). After the nasal and paranasal cavity surgeries in approaches (1) and (3), a 08 or 308, 4-mm rigid endoscope was immobilized in one nostril using a retaining device (Storz1, Germany). In addition, an endoscope cleaning device (Endoscrub, Xomed1; USA) was attached to prevent clouding of the endoscope due to blood. A navigation system (Insta Track Visualization Technology Inc.1; USA) was used to identify the location of the tumor and the juxtapositions of the vital organs. At this point, a neurosurgeon took over and performed the resection of the pituitary tumor like. After the tumor had been almost eliminated, the endoscope was freed from its retainet and inserted into the sella turcica, and the residual tumor tissue was extirpated while being viewed. bone filler (APACERAM1 Pentax; Japan) was immobilized at the site of the bone defect in the posterior wall of the sphenoidal sinus with bone cement. In the case of spinal fluid leakage during the operation, fascia and fatty tissue were harvested from the thigh, and the sella was packed with the fatty tissue and covered with the fascia lata, immobilized with bone cement. Gauze nasal packing (Vesukitin1; Japan) was inserted into the nasal and paranasal cavities, completing the surgery. It was anticipated that the patients would be discharged from the hospital in the absence of postoperative complications such as spinal fluid leakage, etc. after removing gauze packing. Macrolide therapy was administered for 2–3 months after the operation to promote epithelization of the paranasal sinus mucosa [9]. All of the patients were operated on by the same ENT doctor and neurosurgeon.
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
59
Fig. 1. The three endoscopic transnasal transethmoidal surgery (TTES) approaches. In the bilateral TTES approach, the bilateral ethmoidal and sphenoidal sinuses are opened and the middle and superior turbinate were shift to the lateral wall in order to keep the working space and facilitate the surgical procedures, but at the end of operation the middle and superior turbinate were replaced to the original portion. An endoscope is immobilized in one nostril, and the surgery is performed via the bilateral nasal cavities using both hands. In the unilateral TTES approach, the ethmoidal and sphenoidal sinuses are opened on only one side, an endoscope is put in place, and the surgery is performed using only one hand. In the unilateral TTES and RPS approach, the ethmoidal and sphenoidal sinuses are opened on only one side, the posterior portion of the nasal septum is extensively resected, an endoscope is inserted via the contralateral, unopened side, and the surgery is performed via the opened side using both hands.
2.3. Nasal symptom score
2.6. Statistical analysis
After at least 1 year had passed since the operation, the patient assessed his/her symptoms on a visual analog scale (VAS) using scores of 0–10, where ‘‘0’’ means no symptoms are present and ‘‘10’’ means severe symptoms are present. This method was applied to nasal obstruction, nasal discharge, headache, olfactory disturbances, nasal dryness and overall symptomatic assessment [10].
Statistical significance was performed by nonparametric Mann–Whitney’s U-test because the groups were unmatched. A p value of less than 0.05 was considered statistically significant. All statistical analyses were performed on a personal computer with the statistical package SPSS for Windows (Version 11.0, SPSS, Chicago, IL). 2.7. Informed consent
2.4. CT scan assessment After at least 1 year had passed since the operation, The CT images were subjected to radiological grading using the Lund stage classifications [10]. Each sinus was graded between 0 and 2 (0: no abnormality; 1: partial opacification; 2: total opacification). The total scores for the four left and right paranasal sinuses (anterior and posterior ethmoid, maxillary sinus, frontal sinus, sphenoid sinus) are shown. 2.5. Postoperative endoscopic findings After at least 1 year had passed since the operation, the endoscopic findings for the sphenoidal sinus were assessed as either well healed or abnormal (i.e., mucosal hypertrophy, inflammation, discharge, crusting, middle meatus adhesions and polyposis) [11].
The study was approved by the ethics committee of the Jikei University School of Medicine and was performed with the informed consent of each of the patients. 3. Results 3.1. Surgical procedures The patients consisted of 72 who underwent bilateral TTES, 54 who underwent unilateral TTES and RPN and 6 patients who underwent unilateral TTES. In the patients who were undergoing repeated surgery, the approach was microscopic transseptal transphenoidal surgery in 30 patients and unilateral TTES and bilateral TTES in one patient each. The bilateral TTES approach was the more flexible method and particularly effective for advanced tumors that
60
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
were suprasellar or invasive. On the other hand, the unilateral TTES approach resulted in a limited degree of freedom for the manipulation of the forceps since the forceps, suction tube and endoscope were all inserted via the same nostril. In 12 patients, the unilateral TTES approach was initially selected, but manipulation of the forceps proved difficult because of the advanced state of the tumor or copious bleeding; thus, the approach was changed to the bilateral TTES approach in 4 patients and to the unilateral TTES and RPS approach in the other 8 patients. Especially in cases of ACTH-secreting adenomas, although the tumor was small in size, the surgical procedures were complicated by bleeding, and the ability to use both hands proved to be effective. Comparison of the size of the tumor and the surgical approach revealed that the small tumors were removed by the bilateral TTES approach in one patient and by the unilateral TTES and RPS approach in 16 patients, whereas the unilateral TTES approach was not selected for any patients. For the intrasellar tumors, the approach was bilateral TTES in 26 patients, unilateral TTES and RPS in 20 patients and unilateral TTES in 6 patients. The suprasellar tumors were removed by the bilateral TTES approach in 39 patients and by the unilateral TTES and RPS approach in 18 patients, while the unilateral TTES approach was not selected for any patients. All cases of invasive pituitary tumor were treated by the bilateral TTES approach. In patients who were undergoing repeated surgery, the same route was employed in the case of the bilateral TTES approach, whereas patients who had previously undergone the unilateral TTES approach were changed to the unilateral TTES and RPS approach for the second operation. Regarding the result of the operation, total removal of the tumor was achieved in all of the patients with a small tumor. In the total of 52 patients with an intrasellar tumor, the results showed total removal in 42 patients and subtotal removal in 10 patients. For the 57 patients with suprasellar tumors, the surgery achieved total removal in 18 patients, subtotal removal in 37 patients and partial removal in
6 patients. Only partial removal was achieved in all of the patients with invasive type pituitary tumors. 3.2. CT images Postoperative CT scans of the paranasal cavities showed partial opacification in all of the patients. There were no findings indicative of total opacification or development of a mucocele. Three of the patients for whom the bilateral TTES approach was selected and two patients who underwent the unilateral TTES and RPS approach had had chronic sinusitis prior to the surgery, and the surgery was thus performed in two stages for those patients. Overall, the incidence of abnormal radiological findings for the paranasal sinuses was very small with each of the approaches, and no statistically significant differences existed among them (Fig. 2). 3.3. Postoperative nasal symptoms All three surgical approaches showed low scores for each of the nasal symptom categories of nasal obstruction, nasal discharge and headache. However, the scores for olfactory disturbances and nasal dryness were significantly higher with the bilateral TTES approach compared with the unilateral TTES and RPS approach and the unilateral TTES approach ( p < 0.05). With regard to the overall document, as well, the score was higher with the bilateral TTES approach compared with both the unilateral TTES and RPS approach and the unilateral TTES approach, but without statistical significance (Fig. 3). 3.4. Overall postoperative findings for the ethmoidal and sphenoidal sinuses The ratios of well-healed sinuses following the surgery by the bilateral TTES approach, the unilateral TTES and RPS approach and the unilateral TTES approach revealed very good results: 132/144 (92.6%), 47/54 (87.0%) and 6/6
Fig. 2. Postoperative CT images for the unilateral TTES and RPS approach. The right ethmoidal sinuses were opened, and the posterior portion of the nasal septum was resected. The images show the APACERAM1 bone filler that was used to create a floor for the sella.
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
61
Fig. 3. Comparison of the nasal symptoms with each TTES approach. The plots show, from the top, the values for the 10th, 25th, 50th, 75th and 90th percentiles. There were no statistically significant differences among the three TTES approaches with regard to the postoperative incidences of nasal obstruction, nasal discharge or headache. However, the incidences of olfactory disturbances and nasal dryness were significantly higher with the bilateral TTES approach than with the unilateral TTES approach ( p < 0.05).
(100%), respectively (Fig. 4 and Table 1). The most common abnormal findings consisted of pus discharge in the sphenoidal sinuses, partial adhesion of the middle meatus and partial adhesion of the olfactory cleft. Improvement of
the infection in the sphenoidal sinuses was achieved by flushing with physiological saline solution and administration of antibiotics. Also, the adhesions of the middle meatus and olfactory cleft were later surgically freed. A nasal
Fig. 4. Postoperative endoscopic nasal findings with the unilateral TTES and RPS approach. The right ethmoidal sinuses were opened (upper right), and the mucosa of the ethmoidal and sphenoidal sinuses is seen to be good. The APACERAM1 bone filler that was used to create a floor for the sella can be seen (*).
62
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
Table 1 Postoperative endoscopic findings for the ethmoidal and sphenoidal sinuses
With each of the three TTES approaches, the mucosal lining was observed to be well healed in about 90% of the patients. There were more cases of partial adhesion of the middle meatus or olfactory cleft in the patients operated upon by the bilateral TTES approach and the unilateral TTES and RPS approach. * Healthy mucosal lining and with no evidence of inflammation, mucosal swelling, hypertrophy, polyposis or scarring.
septum perforation was noted in 21 of 30 patients who had previously undergone microscopic transseptal transsphenoidal surgery, but this abnormality was not observed after switching the surgical technique to the TTES approach. 3.5. Complications Spinal fluid leakage occurred immediately after the surgery in a total of seven patients, consisting of five patients with suprasellar disease and two patients with invasive disease. Within several days the leakage site was repaired via the same operative route in each of these patients by using fatty tissue and fascia that had been harvested from the thigh area.
4. Discussion A middle meatus approach for pituitary tumor is reported to be seldom used excepted as a straight approach to the ipsilateral cavernous sinu [12]. Although our approach is similar to the above the middle meatus approach at the point of opening both the ethmoidal and sphenoidal sinuses, the TTES approach not only create a sufficient working space for removal of the tumor by shifting the middle and superior turbinate to the lateral wall, but also during the surgery prevent occlusion of the OMC due to displacement of the medial wall of the nasal cavity – especially the nasal turbinate bones – caused by the surgical tools or endoscope [7]. After application of the bilateral TTES approach, the paranasal sinuses were confirmed to show good epithelization in 92.6% of the patients, and postoperative CT images also did not reveal any problematic sinusitis. However, comparison of the postoperative nasal symptoms between the unilateral TTES approach and the bilateral TTES approach showed that nasal obstruction, nasal discharge and headache did not represent significant problems with either approach, whereas the numbers of patients complaining of
olfactory disturbances and nasal dryness were statistically increased in the case of the bilateral TTES approach. Therefore, with the objective of reducing the invasiveness to the paranasal sinuses, we introduced the unilateral TTES and PRS approach. With this unilateral TTES and PRS approach, we have been able to reduce the incidences of postoperative olfactory disturbances and nasal dryness to about the same as with the unilateral TTES approach. With all three of the surgical approaches analyzed in this report, about 90% of the endoscopic images of the postoperative paranasal sinuses were rated as well healed. The bilateral TTES approach patients and the unilateral TTES and PRS approach patients showed high incidences of partial adhesion of the middle meatus and the olfactory cleft, but none of these cases aggravated to the point of formation of a mucocele. In the CT images, as well, the incidence of abnormal shadows in each of the paranasal sinuses was within 3%, and the overall results indicated good epithelization of the paranasal sinus mucosa. In endoscopic surgery for pituitary tumors accompanied by bleeding, the selection of the surgical approach must be based on consideration of not just the size and the degree of progression of the tumor, but also the extent of bleeding in the operative field. When the amount of bleeding is large, surgical manipulations with only one hand become difficult. For the present patient series, the unilateral TTES approach was initially selected for small tumors, but bimanual manipulation is necessary in the event of bleeding at the time of extirpation of the tumor, and for this reason we have more recently switched to the bilateral TTES approach or the unilateral TTES and PRS approach for such small adenomas. Overall consideration of the surgical manipulability and the postoperative complications and nasal symptoms leads us to surmise that the unilateral TTES and PRS approach is for us the most suitable technique, and that the bilateral TTES approach is best suited for large, advanced tumors because of the high degree of freedom it affords for the
S. Haruna et al. / Auris Nasus Larynx 34 (2007) 57–63
surgical manipulations. On the other hand, in the case of the unilateral TTES approach it is difficult to perform the resection of tumors that have advanced to the contralateral side. In addition, since the endoscope, forceps and suction tube are all inserted into the same paranasal sinus, these tools bump into each other and the surgical procedures are difficult to execute. Therefore, we think that the unilateral TTES approach is most appropriate for removal of tumors that are deviated to one side and localized within the sella. In conclusion, for performance of endoscopic surgery on pituitary tumors that are accompanied by bleeding in the operative field, the surgical approach should be selected in order to secure the visual field and surgical manipulability that will be needed in consideration of the degree of progression of the tumor and its location. In addition, it is important to select an approach that is minimally invasive to the paranasal sinuses.
References [1] Hardy J. Transsphenoidal microsurgery of the normal and pathological puitary. Clin Neurosurg 1969;16:185–217.
63
[2] Sethi DS, Leonf JL. Endoscopic pituitary surgery. Otolaryngol Clin North Am 2006;39:563–83. [3] White DR, Sonnenburg RE, Ewend MG, Senior BA. Safety of minimally invasive pituitary surgery (MIPS) compared with a traditional approach. Laryngoscope 2004;114:1945–8. [4] Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 1997;87:44–51. [5] Cappabianca P. Endoscopic endonasal transspenoidal surgery. Neurosurgery 2004;55:933–41. [6] Jankowski R. Endoscopic pituitary surgery. Larngoscope 1992;102:198–202. [7] Otori N, Haruna S, Kamio M, Ohashi G, Moriyama H. Endoscopic transethomoidal approach for pituitary tumors with image guidance. Am J Rhinol 2001;15(6):381–6. [8] Thomas RF, Monacci WT, Mair EA. Endoscopic image-guided transethmoid pituitary surgery. Otolaryngol Head Neck Surg 2002;127:409–16. [9] Moriyama H, Yanagi K, Ohtori N, Fukami M. Evaluation of endoscopic sinus surgery for chronic sinusitis: post-operative erythromycin therapy. Rhinology 1995;33(3):166–70. [10] Valerie JL, Ian SM. Staging in rhinosinusitis. Rhinology 1993;31:183– 4. [11] Kennedy DW. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 1992;102(Suppl 57):1–18. [12] Jho HD, Affieri. Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition. Br J Neurosurg 2000;14(5):432–40.