- Email: [email protected]
Nasal septum after sublabial transseptal transsphenoidal pituitary surgery
Nasal septum after sublabial transseptal transsphenoidal pituitary surgery ANDREW C. URQUHART, MD, FCS(SA),FERNANDO B. BERSALONA,MD, FACS,VICTOR S. EJERCITO, MD, FACS,and JAMES J. HOLT, MD, FACS,Marshfield, Wisconsin Transseptal transsphenoidal approach to the pituitary fossa is a well-described and effective procedure. This article relates our experience with this procedure with specific emphasis on the nasal septum, both before and after surgery. It has been our experience that this surgery has minimal local complications in the nose and it would appear to improve septal alignment with subjective improvement in nasal function as reported by the patient. A total of 55 patients undergoing a sublabial transseptal transsphenoidal approach to the pituitary fossa were included in this study. All other approaches to the pituitary gland were excluded. Visual changes and headaches were the most common presenting symptoms, occurring alone or in combination in 28 (51%) patients. Twelve (22%) patients reported symptoms of nasal obstruction before surgery and only one (2%) after surgery. A moderately or severely deviated septum was noted in 30 (54%) patients before surgery and 4 (7%) patients after surgery. The septum was straight in 21 (38%) patients before the procedure and 49 (89%) patients afer the surgery. Sinusitis developed in two patients, and one patient subsequently required surgery. No synechiae or septal perforations were noted. (Otoloryngol Heod Neck Surg ] 996; 115:64-9.)
|
I n 1909 Hirsch ~ described a modified endonasal approach to the sella with the use of the Killian submucosal resection of the septum and preservation of intact intranasal mucosal flaps. Halstead placed an incision in the gingivolabial sulcus and modified the inferior rhinotomy approaches. These two approaches were combined by Cushing and used for hundreds of pituitary resections between 1912 and 1925. 2 There was a low operative mortality rate, but Cushing later changed his approach to a transfrontal craniotomy because of the often extensive extrasellar tumor extension that he encountered. The transsphenoidal approaches to the pituitary fossa fell out of use until their revival in the 1950s after Luft and Olivecrona 3 reported on the removal of the normal pituitary gland for hormonally dependent metastatic adenocarcinoma. Meningitis no longer posed the serious risk that it did in the preantibiotic era. Cortisone also became readily available. From the Department of Otolaryngology/I-teadand Neck Surgery, Marshfield Clinic. Received for publication March 21, 1995; revision received Nov. 9, 1995; accepted Nov. 10, 1995. Reprint requests: Andrew C. Urquhart, MD, Department of Otolaryngology/Headand Neck Surgery,Marshfield Clinic, 1000North Oak Ave., Marshfietd, WI 54449. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 + 0 23/1/70"640 64
The approach to the sphenoid sinus requires dislocation of the septum with partial resection of the vomer and anterior face of the sphenoid. The purpose of this article is to discuss the approach to the pituitary fossa from an otolaryngologic perspective. Special emphasis is placed on the surgical technique, as well as the preoperative and postoperative assessment of the nasal cavity and the airway. Note is made of the low morbidity rate and few local complications associated with this procedure, as well as the beneficial effects to the patient's airway.
METHODS AND MATERIAL We performed a retrospective chart review on all patients who underwent a sublabial transseptal transsphenoidal approach to the pituitary fossa at the Marshfield Clinic and St. Joseph' s Hospital between 1979 and 1993. All other approaches to the pituitary gland were excluded from the study. The age, sex, presenting symptoms, preoperative and postoperative otolaryngologic and visual findings, initial radiologic investigation, pathology, duration of hospitalization, follow-up, use of radiotherapy, and complications in the immediate and subsequent follow-up period were recorded. Special attention was given to the preoperative and postoperative nasal findings with specific documentation of symptoms of nasal obstruction and the appearance of the septum. After surgery, any findings of synechiae, per-
Otolaryngology Head and Neck Surgery Volume 115 Number 1
URQUHART et al.
i
65
X
Fig. 1. Dislocation of septal c a r t i l a g e off m a x i l l a r y crest.
forations, mucosal changes, or episodes of sinusitis were sought. PROCEDURE
All of the procedures are performed in conjunction with a neurosurgeon. The patient is positioned in the supine position. After induction of general anesthesia, the nose is packed with cottonoid pledgets soaked in 4% cocaine solution and eight drops of 1 : 1000 epinephrine (Adrenalin) on eith'er side. A columella clamp is applied so that the distal end of the septum is visualized. Using a no. 15 blade, an incision is made on the right, The mucoperichondrium is elevated on the left with a Cottle knife. A skin hook is used to retract the septum. Once partially elevated, the submucus knife is used to dislocate the septal cartilage off the maxillary crest (Fig. 1). The mucoperichondrium is elevated on either side of the vomer onto the face of the sphenoid with the Cottle elevator. Double-action Becket scissors are used to cut the vomer before removing the bony fragments with Takahashi forceps. With the curved Cottle elevator, inferior tunnels are raised on either side. The Neivert retractor is used to retract the overlying tissue in the area of the columella incision so that the maxillary crest is exposed. Using cautery with the needle tip, the tissue is cut off the maxillary crest. With a MacKenty elevator, the tissue is elevated off the maxilla to expose the pyriform aperture on either side. With the acute angle of the Cottle elevator, the mucosa is elevated off the anterior floor of the nasal cavity, and with the less acute angle,
the tunnels are elevated further posteriorly. A sublabial incision is made fl'om incisor to incisor, and the large sphenoid speculum is inserted (Fig. 2). It is opened and closed slowly as it is advanced to the face of the sphenoid (Fig. 3). The microscope is now used, and the rostrum of the sphenoid with the ostia is identified. A Cottle elevator is placed into the ostium, and the position is verified with an image intensifier. The anterior face of the sphenoid is removed with a Kerrison rongeur and Takahashi forceps. The mucosa is removed anteriorly, and the sinus cavity should be well visualized. The neurosurgical part of the procedure is now performed with entry into the pituitary fossa and tumor removal. After this is completed, the sphenoid sinus is packed with fat, and bone fragments are repositioned to reconstruct the anterior face of the sphenoid and septum. The septum is now sutured to the maxillary crest with Vicryl. A Keith needle with 3-0 chromic is passed through the right mucoperichondrial incision to a small puncture made with a no. 11 blade in either nasolabial fold. The suture remains in the sublabial incision and serves to support the base of the nose. The mucoperichondrium incision is closed with 3-0 interrupted chromic sutures, and the sublabial incision is closed with .3-0 Vicryl. Silastic splints and nasal packs are inserted for 7 days. RESULTS
A total of 55 patients underwent pituitary surgery with the sublabial transseptal transsphenoidal approach.
Otolaryngology Head and Neck Surgery 66
URQUHART et al.
JuLy 1996
Fig. 2. Sublabial incision,
Table 1 Presenting symptoms
Fig. 3. Insertion of sphenoid speculum.
Twenty-six were male, and 29 were female, The ages ranged from 23 to 81 years, with an average of 52.5 years. The average duration of hospitalization was 8.3 days, and follow-up was 46.5 months. Visual changes and headaches were the most common presenting symptoms (Table 1), occurring alone or in combination in 28 (51%) patients. The preoperative and postoperative otolaryngologic
(n = 55)
Syrnptoms
No. of patients
Visual Headaches Visual and headaches Endocrine ~yperprotacunemLa with or without amenorrnea Acromegaly Other Routine dnys~ca' Miscellaneous Gait disturbance Seizures Breast carcinoma Pros[auc ;arcinoma Dementia
17 8 3 9 4 5 4 1 1 1 1 1
findings are listed in Table 2. Twelve (22%) patients reported symptoms of nasal obstruction before surgery and only one (2%) after surgery. A moderately or severely deviated sepmm was noted in 30 (54%) patients before surgery and 4 (7%) patients after surgery. The surgeon believed that the septum was straight in 21 (38%) patients before the procedure and 49 (89%) patients alter surgery. Visual fields were performed on 44 patients before surgery and 37 after surgery. Eighteen patients had preoperative field changes (17 bitemporal hemianopia, 1 left temporal hemianopia). After surgery, 4 patients had normal visual fields, and 13 patients had bitemporal hemianopia, 12 of which had improved. The one left temporal hcmianopia remained unchanged. Initial radiology to diagnose the tumor was a computed tomography scan in 31 patients and a magnetic
Otolaryngology Head and Neck Surgery
Volume 115 Number 1
URQUHART et al.
67
Fig. 5. C o m p u t e d t o m o g r a p h y scan of the s a m e patient showing large pituitary tumor. Fig. 4. Lateral skull x-ray film as part of a sinus series ord e r e d b y the p r i m a r y care physician. Enlarged sella was noted, a n d a follow-up c o m p u t e d t o m o g r a p h y scan was done.
resonance imaging scan in 18 patients, and both modalities were used in 6 patients. Pathologic diagnoses are listed in Table 3. Pituitary adenoma was the most common, occurring in 51 (93%) patients. Thirty-three (60%) patients underwent postoperative radiation therapy. No patients had undergone radiation therapy before surgery. Complications were divided into otolaryngologic and general complications (Table 4). Diabetes insipidus was the most common general complication, occurring in 19 (34.5%) patients. There were few otolaryngologic complications, with sinusitis developing in two patients some months after the surgery and intrasellar sepsis developing in one patient 5 weeks after surgery. There were no synechiae or septal perforations. DISCUSSION
Transseptal transsphenoidal pituitary surgery offers an excellent, low-morbidity approach to the pituitary fossa. Indications include pituitary tumors that extend inferiorly with enlargement of the sella floor and invasion of the sphenoid sinus, as well as microadenomas
localized to the sella without dural invasion. Transsphenoidal removal of pituitary adenomas with slight suprasellar extension is also generally effective. There have been four transseptal approaches described in the literature: the sublabial transseptal technique, open rhinoplasty, alotomy with anterior septal dissection, and alotomy with posterior septal dissection. In our series of 55 patients, the sublabial transseptal transsphenoidal approach offered excellent visualization and exposure with no evidence of any external cosmetic deformity. Although it has been reported that the combination of Adrenalin with cocaine is not necessary, we have had no adverse reactions and obtain good decongestion. We found visual changes and headache to be the most common presenting symptoms. This is important because the patients often went to primary care physicians with either or both of those being their only symptom. From an otolaryngologic standpoint, three patients had symptoms suggestive of sinusitis, and the enlarged sella was noted on the lateral skull view. Two other patients had x-ray films done, one for head trauma and one for neck pain, and enlargement of the sella was noted. Five (9%) patients therefore had suspicious findings on routine x-ray films that led to further investigation with either magnetic resonance imaging or computed tomography scans (Figs. 4 and 5). Nasal obstruction was reported by 12 patients be-
Otolaryngology Head and Neck Surgery 68
July 1996
URQUHARTet al,
Table 2. P r e o p e r a t i v e a n d p o s t o p e r a t i v e o t o l a r y n g o l o g i c findings (n = 55) Findings
Preoperative
Postoperative
Symptoms of nasal obstruction Septum Straight Moderate deviation/spur Severe deviation/spur Not noted
12
1
21 20 11 3
49 4 0 2
Table 4. C o m p l i c a t i o n s (n = 55)
T a b l e 3. P a t h o l o g y (n = 55) Pathology
No. of patients
Complications
Pituitary adenoma Normal pituitary gland Infarcted gland Infarcted tumor Carcinoma of the nasopharynx
51 1 1 1 1
General Diabetes insipidus Transient psychosis Deep venous thrombosis Cerebrospinal fluid leak Otolaryngologic Sinusitis IntraseIlar sepsis Septal perforation Synechiae
fore surgery and by only 1 after surgery. Although no objective method was used to assess nasal function, the septum was believed to be straight in 89% of patients after surgery, compared with 38% before surgery. Quite clearly, the septal surgery resulted in a symptomatic improvement in nasal function, with postoperative evidence of good septal alignment. The benefit of a combined approach with an otolaryngologist familiar with septal surgery was well demonstrated, not only in terms of resection of the tumor but also in terms of the coincidental positive effects of the septal surgery. An improvement in visual fields after surgery has been noted to be between 66.7% and 90%. 4,5 Eighteen (33%) patients had preoperative field changes. Of this group, 16 (89%) patients were either normal or improved after surgery. The close anatomic relationship of the pituitary gland to the optic chiasm results in compression with subsequent visual field defects. Bilateral hemianopia is the most frequent defect. The incidence of chromophobe tumors is the greatest, although chromophobe cells are the least numerous/~ Most of our patients belonged to this group, although one patient had a carcinoma of the nasopharynx eroding up into the pituitary fossa. Sixty percent of our patients underwent postoperative radiation therapy. This decision was usually made by both the surgeon and endocrinologist involved. Generally, if there was obvious remaining tumor or hormonal levels remained high in secreting tumors, radiotherapy was given. It is generally agreed that postoperative radiotherapy has improved the long-term results of pituitary adenoma? 'v
No, of patients
19 1 1 0 2 1 0 0
The most frequently reported complication in several series reviewed was diabetes insipidus. 4'8'9This occurred in 34.5% of our group. Most of these patients responded to increased fluid and DDAVR and all of their symptoms resolved during the follow-up period. Cerebrospinal fluid leak occurred between 0.7% and 9.6% in the series reviewed. 8'~°We did not have any documented postoperative leaks. All of the sphenoid cavities were packed with fat, and muscle and fascia were also used in some situations. Lumbar drains were placed in some cases, but this depended on the neurosurgeon's preference. Otolaryngologic complications were rare in our series. Maxillary sinusitis developed in two patients, and one of them required a surgical procedure at a later stage. One patient had what was believed to be sepsis in the sella, and this responded to intravenous antibiotics. Septal perforation has been reported to occur in up to 9% of cases. ~ In a more recent article advocating an external rhinoplasty approach, 8 symptomatic anterior septal perforations and 13 asymptomatic posterior perforations were noted in a series of 111 patients. ~2These authors suggested that septal perforations were common by any technique because of excessive spreading of the septal leaflets by the speculum. We were fortunate not to have any septal perforations, synechiae, or adhesions. Temporary numbness of the upper lip and teeth is thought to occur as a result of injury to the anterior superior alveolar nerves. We expected this to occur in most patients, and they were informed of this before
Otolaryngology Head and Neck Surgery V o l u m e 115 N u m b e r 1
surgery. T h e lack o f reports o f this c o m m o n postoperative s y m p t o m is probably explained by the low degree o f associated morbidity. CONCLUSION
Transseptal transsphenoidal approach to the pituitary fossa is a safe and effective procedure with a low morbidity and few local complications. Visual symptoms and h e a d a c h e s were the most c o m m o n presenting symptoms. T h e surgical approach appeared to i m p r o v e septal alignment with a corresponding s y m p t o m a t i c i m p r o v e m e n t in nasal breathing. The i n c i d e n c e o f septal perforations and synechiae appears to be insignificant c o m p a r e d with the benefits d e r i v e d from this approach. REFERENCES
I. Hirsch O. Symptoms and treatment of pituitary tumors. Arch Otolaryngol 1952;55:268-306. 2. Henderson WR. The pituitary adenomata: a follow-up study of the surgical results in 338 cases (Dr. Cushing's series). Br J Surg 1939;26:811-921.
URQUHART et al.
69
3. Luft R, Otivecrona H. Experiences with hypophysectomy in man. J Neurosurg 1953;10:301-t6. 4. Wilson CB, Dempsey LC. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 1978;48:13-22. 5. Ciric l, Mikhael M, Stafford T, Lawson L, Graces R. Transsphenoidal microsurgery of pituitary microadenomas with long-term follow-up results. J Neurosurg 1983;59:395-401. 6. Hayes TP, Davis RA, Raventos A. The treatment of pituitary chromophobe adenomas. Radiology 1971 ;98:149-53. 7. Ray BS, Patterson RH Jr. Surgical experience with chromophobe adenomas of the pituitary gland. J Neurosurg 1971;34:726-9. 8. Kennedy DW, Cohn ES, Papel 1D, Holliday MJ. Transsphenoidal approach to the sella: the Johns Hopkins experience. Laryngoscope 1984;94:1066-74. 9. Eisele DW, Flint PW, Janas JD, Kelly WA, Weymuller EA Jr, Cummings CW. The sublabial transseptal transsphenoidal approach to sellar and parasetlar lesions. Laryngoscope 1988;98: 1301-8. I0. Kern EB. Transnasal pituitary surgery. Arch Otolaryngol 1981; 107:183-90. 11. Sherwen PJ, Patterson WJ, Griesdale DE. Transseptal, transsphenoidal surgery: a subjective and objective analysis of results. J Otolaryngol 1986; 15:155-60. 12. Koltai PJ, Goufman DB, Parnes SM, Steiniger JR. Transsphenoidal hypophysectomy through the external rhinoplasty approach. Otolaryngol Head Neck Surg 1994;11l:197-200.
|
I n 1909 Hirsch ~ described a modified endonasal approach to the sella with the use of the Killian submucosal resection of the septum and preservation of intact intranasal mucosal flaps. Halstead placed an incision in the gingivolabial sulcus and modified the inferior rhinotomy approaches. These two approaches were combined by Cushing and used for hundreds of pituitary resections between 1912 and 1925. 2 There was a low operative mortality rate, but Cushing later changed his approach to a transfrontal craniotomy because of the often extensive extrasellar tumor extension that he encountered. The transsphenoidal approaches to the pituitary fossa fell out of use until their revival in the 1950s after Luft and Olivecrona 3 reported on the removal of the normal pituitary gland for hormonally dependent metastatic adenocarcinoma. Meningitis no longer posed the serious risk that it did in the preantibiotic era. Cortisone also became readily available. From the Department of Otolaryngology/I-teadand Neck Surgery, Marshfield Clinic. Received for publication March 21, 1995; revision received Nov. 9, 1995; accepted Nov. 10, 1995. Reprint requests: Andrew C. Urquhart, MD, Department of Otolaryngology/Headand Neck Surgery,Marshfield Clinic, 1000North Oak Ave., Marshfietd, WI 54449. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 + 0 23/1/70"640 64
The approach to the sphenoid sinus requires dislocation of the septum with partial resection of the vomer and anterior face of the sphenoid. The purpose of this article is to discuss the approach to the pituitary fossa from an otolaryngologic perspective. Special emphasis is placed on the surgical technique, as well as the preoperative and postoperative assessment of the nasal cavity and the airway. Note is made of the low morbidity rate and few local complications associated with this procedure, as well as the beneficial effects to the patient's airway.
METHODS AND MATERIAL We performed a retrospective chart review on all patients who underwent a sublabial transseptal transsphenoidal approach to the pituitary fossa at the Marshfield Clinic and St. Joseph' s Hospital between 1979 and 1993. All other approaches to the pituitary gland were excluded from the study. The age, sex, presenting symptoms, preoperative and postoperative otolaryngologic and visual findings, initial radiologic investigation, pathology, duration of hospitalization, follow-up, use of radiotherapy, and complications in the immediate and subsequent follow-up period were recorded. Special attention was given to the preoperative and postoperative nasal findings with specific documentation of symptoms of nasal obstruction and the appearance of the septum. After surgery, any findings of synechiae, per-
Otolaryngology Head and Neck Surgery Volume 115 Number 1
URQUHART et al.
i
65
X
Fig. 1. Dislocation of septal c a r t i l a g e off m a x i l l a r y crest.
forations, mucosal changes, or episodes of sinusitis were sought. PROCEDURE
All of the procedures are performed in conjunction with a neurosurgeon. The patient is positioned in the supine position. After induction of general anesthesia, the nose is packed with cottonoid pledgets soaked in 4% cocaine solution and eight drops of 1 : 1000 epinephrine (Adrenalin) on eith'er side. A columella clamp is applied so that the distal end of the septum is visualized. Using a no. 15 blade, an incision is made on the right, The mucoperichondrium is elevated on the left with a Cottle knife. A skin hook is used to retract the septum. Once partially elevated, the submucus knife is used to dislocate the septal cartilage off the maxillary crest (Fig. 1). The mucoperichondrium is elevated on either side of the vomer onto the face of the sphenoid with the Cottle elevator. Double-action Becket scissors are used to cut the vomer before removing the bony fragments with Takahashi forceps. With the curved Cottle elevator, inferior tunnels are raised on either side. The Neivert retractor is used to retract the overlying tissue in the area of the columella incision so that the maxillary crest is exposed. Using cautery with the needle tip, the tissue is cut off the maxillary crest. With a MacKenty elevator, the tissue is elevated off the maxilla to expose the pyriform aperture on either side. With the acute angle of the Cottle elevator, the mucosa is elevated off the anterior floor of the nasal cavity, and with the less acute angle,
the tunnels are elevated further posteriorly. A sublabial incision is made fl'om incisor to incisor, and the large sphenoid speculum is inserted (Fig. 2). It is opened and closed slowly as it is advanced to the face of the sphenoid (Fig. 3). The microscope is now used, and the rostrum of the sphenoid with the ostia is identified. A Cottle elevator is placed into the ostium, and the position is verified with an image intensifier. The anterior face of the sphenoid is removed with a Kerrison rongeur and Takahashi forceps. The mucosa is removed anteriorly, and the sinus cavity should be well visualized. The neurosurgical part of the procedure is now performed with entry into the pituitary fossa and tumor removal. After this is completed, the sphenoid sinus is packed with fat, and bone fragments are repositioned to reconstruct the anterior face of the sphenoid and septum. The septum is now sutured to the maxillary crest with Vicryl. A Keith needle with 3-0 chromic is passed through the right mucoperichondrial incision to a small puncture made with a no. 11 blade in either nasolabial fold. The suture remains in the sublabial incision and serves to support the base of the nose. The mucoperichondrium incision is closed with 3-0 interrupted chromic sutures, and the sublabial incision is closed with .3-0 Vicryl. Silastic splints and nasal packs are inserted for 7 days. RESULTS
A total of 55 patients underwent pituitary surgery with the sublabial transseptal transsphenoidal approach.
Otolaryngology Head and Neck Surgery 66
URQUHART et al.
JuLy 1996
Fig. 2. Sublabial incision,
Table 1 Presenting symptoms
Fig. 3. Insertion of sphenoid speculum.
Twenty-six were male, and 29 were female, The ages ranged from 23 to 81 years, with an average of 52.5 years. The average duration of hospitalization was 8.3 days, and follow-up was 46.5 months. Visual changes and headaches were the most common presenting symptoms (Table 1), occurring alone or in combination in 28 (51%) patients. The preoperative and postoperative otolaryngologic
(n = 55)
Syrnptoms
No. of patients
Visual Headaches Visual and headaches Endocrine ~yperprotacunemLa with or without amenorrnea Acromegaly Other Routine dnys~ca' Miscellaneous Gait disturbance Seizures Breast carcinoma Pros[auc ;arcinoma Dementia
17 8 3 9 4 5 4 1 1 1 1 1
findings are listed in Table 2. Twelve (22%) patients reported symptoms of nasal obstruction before surgery and only one (2%) after surgery. A moderately or severely deviated sepmm was noted in 30 (54%) patients before surgery and 4 (7%) patients after surgery. The surgeon believed that the septum was straight in 21 (38%) patients before the procedure and 49 (89%) patients alter surgery. Visual fields were performed on 44 patients before surgery and 37 after surgery. Eighteen patients had preoperative field changes (17 bitemporal hemianopia, 1 left temporal hemianopia). After surgery, 4 patients had normal visual fields, and 13 patients had bitemporal hemianopia, 12 of which had improved. The one left temporal hcmianopia remained unchanged. Initial radiology to diagnose the tumor was a computed tomography scan in 31 patients and a magnetic
Otolaryngology Head and Neck Surgery
Volume 115 Number 1
URQUHART et al.
67
Fig. 5. C o m p u t e d t o m o g r a p h y scan of the s a m e patient showing large pituitary tumor. Fig. 4. Lateral skull x-ray film as part of a sinus series ord e r e d b y the p r i m a r y care physician. Enlarged sella was noted, a n d a follow-up c o m p u t e d t o m o g r a p h y scan was done.
resonance imaging scan in 18 patients, and both modalities were used in 6 patients. Pathologic diagnoses are listed in Table 3. Pituitary adenoma was the most common, occurring in 51 (93%) patients. Thirty-three (60%) patients underwent postoperative radiation therapy. No patients had undergone radiation therapy before surgery. Complications were divided into otolaryngologic and general complications (Table 4). Diabetes insipidus was the most common general complication, occurring in 19 (34.5%) patients. There were few otolaryngologic complications, with sinusitis developing in two patients some months after the surgery and intrasellar sepsis developing in one patient 5 weeks after surgery. There were no synechiae or septal perforations. DISCUSSION
Transseptal transsphenoidal pituitary surgery offers an excellent, low-morbidity approach to the pituitary fossa. Indications include pituitary tumors that extend inferiorly with enlargement of the sella floor and invasion of the sphenoid sinus, as well as microadenomas
localized to the sella without dural invasion. Transsphenoidal removal of pituitary adenomas with slight suprasellar extension is also generally effective. There have been four transseptal approaches described in the literature: the sublabial transseptal technique, open rhinoplasty, alotomy with anterior septal dissection, and alotomy with posterior septal dissection. In our series of 55 patients, the sublabial transseptal transsphenoidal approach offered excellent visualization and exposure with no evidence of any external cosmetic deformity. Although it has been reported that the combination of Adrenalin with cocaine is not necessary, we have had no adverse reactions and obtain good decongestion. We found visual changes and headache to be the most common presenting symptoms. This is important because the patients often went to primary care physicians with either or both of those being their only symptom. From an otolaryngologic standpoint, three patients had symptoms suggestive of sinusitis, and the enlarged sella was noted on the lateral skull view. Two other patients had x-ray films done, one for head trauma and one for neck pain, and enlargement of the sella was noted. Five (9%) patients therefore had suspicious findings on routine x-ray films that led to further investigation with either magnetic resonance imaging or computed tomography scans (Figs. 4 and 5). Nasal obstruction was reported by 12 patients be-
Otolaryngology Head and Neck Surgery 68
July 1996
URQUHARTet al,
Table 2. P r e o p e r a t i v e a n d p o s t o p e r a t i v e o t o l a r y n g o l o g i c findings (n = 55) Findings
Preoperative
Postoperative
Symptoms of nasal obstruction Septum Straight Moderate deviation/spur Severe deviation/spur Not noted
12
1
21 20 11 3
49 4 0 2
Table 4. C o m p l i c a t i o n s (n = 55)
T a b l e 3. P a t h o l o g y (n = 55) Pathology
No. of patients
Complications
Pituitary adenoma Normal pituitary gland Infarcted gland Infarcted tumor Carcinoma of the nasopharynx
51 1 1 1 1
General Diabetes insipidus Transient psychosis Deep venous thrombosis Cerebrospinal fluid leak Otolaryngologic Sinusitis IntraseIlar sepsis Septal perforation Synechiae
fore surgery and by only 1 after surgery. Although no objective method was used to assess nasal function, the septum was believed to be straight in 89% of patients after surgery, compared with 38% before surgery. Quite clearly, the septal surgery resulted in a symptomatic improvement in nasal function, with postoperative evidence of good septal alignment. The benefit of a combined approach with an otolaryngologist familiar with septal surgery was well demonstrated, not only in terms of resection of the tumor but also in terms of the coincidental positive effects of the septal surgery. An improvement in visual fields after surgery has been noted to be between 66.7% and 90%. 4,5 Eighteen (33%) patients had preoperative field changes. Of this group, 16 (89%) patients were either normal or improved after surgery. The close anatomic relationship of the pituitary gland to the optic chiasm results in compression with subsequent visual field defects. Bilateral hemianopia is the most frequent defect. The incidence of chromophobe tumors is the greatest, although chromophobe cells are the least numerous/~ Most of our patients belonged to this group, although one patient had a carcinoma of the nasopharynx eroding up into the pituitary fossa. Sixty percent of our patients underwent postoperative radiation therapy. This decision was usually made by both the surgeon and endocrinologist involved. Generally, if there was obvious remaining tumor or hormonal levels remained high in secreting tumors, radiotherapy was given. It is generally agreed that postoperative radiotherapy has improved the long-term results of pituitary adenoma? 'v
No, of patients
19 1 1 0 2 1 0 0
The most frequently reported complication in several series reviewed was diabetes insipidus. 4'8'9This occurred in 34.5% of our group. Most of these patients responded to increased fluid and DDAVR and all of their symptoms resolved during the follow-up period. Cerebrospinal fluid leak occurred between 0.7% and 9.6% in the series reviewed. 8'~°We did not have any documented postoperative leaks. All of the sphenoid cavities were packed with fat, and muscle and fascia were also used in some situations. Lumbar drains were placed in some cases, but this depended on the neurosurgeon's preference. Otolaryngologic complications were rare in our series. Maxillary sinusitis developed in two patients, and one of them required a surgical procedure at a later stage. One patient had what was believed to be sepsis in the sella, and this responded to intravenous antibiotics. Septal perforation has been reported to occur in up to 9% of cases. ~ In a more recent article advocating an external rhinoplasty approach, 8 symptomatic anterior septal perforations and 13 asymptomatic posterior perforations were noted in a series of 111 patients. ~2These authors suggested that septal perforations were common by any technique because of excessive spreading of the septal leaflets by the speculum. We were fortunate not to have any septal perforations, synechiae, or adhesions. Temporary numbness of the upper lip and teeth is thought to occur as a result of injury to the anterior superior alveolar nerves. We expected this to occur in most patients, and they were informed of this before
Otolaryngology Head and Neck Surgery V o l u m e 115 N u m b e r 1
surgery. T h e lack o f reports o f this c o m m o n postoperative s y m p t o m is probably explained by the low degree o f associated morbidity. CONCLUSION
Transseptal transsphenoidal approach to the pituitary fossa is a safe and effective procedure with a low morbidity and few local complications. Visual symptoms and h e a d a c h e s were the most c o m m o n presenting symptoms. T h e surgical approach appeared to i m p r o v e septal alignment with a corresponding s y m p t o m a t i c i m p r o v e m e n t in nasal breathing. The i n c i d e n c e o f septal perforations and synechiae appears to be insignificant c o m p a r e d with the benefits d e r i v e d from this approach. REFERENCES
I. Hirsch O. Symptoms and treatment of pituitary tumors. Arch Otolaryngol 1952;55:268-306. 2. Henderson WR. The pituitary adenomata: a follow-up study of the surgical results in 338 cases (Dr. Cushing's series). Br J Surg 1939;26:811-921.
URQUHART et al.
69
3. Luft R, Otivecrona H. Experiences with hypophysectomy in man. J Neurosurg 1953;10:301-t6. 4. Wilson CB, Dempsey LC. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 1978;48:13-22. 5. Ciric l, Mikhael M, Stafford T, Lawson L, Graces R. Transsphenoidal microsurgery of pituitary microadenomas with long-term follow-up results. J Neurosurg 1983;59:395-401. 6. Hayes TP, Davis RA, Raventos A. The treatment of pituitary chromophobe adenomas. Radiology 1971 ;98:149-53. 7. Ray BS, Patterson RH Jr. Surgical experience with chromophobe adenomas of the pituitary gland. J Neurosurg 1971;34:726-9. 8. Kennedy DW, Cohn ES, Papel 1D, Holliday MJ. Transsphenoidal approach to the sella: the Johns Hopkins experience. Laryngoscope 1984;94:1066-74. 9. Eisele DW, Flint PW, Janas JD, Kelly WA, Weymuller EA Jr, Cummings CW. The sublabial transseptal transsphenoidal approach to sellar and parasetlar lesions. Laryngoscope 1988;98: 1301-8. I0. Kern EB. Transnasal pituitary surgery. Arch Otolaryngol 1981; 107:183-90. 11. Sherwen PJ, Patterson WJ, Griesdale DE. Transseptal, transsphenoidal surgery: a subjective and objective analysis of results. J Otolaryngol 1986; 15:155-60. 12. Koltai PJ, Goufman DB, Parnes SM, Steiniger JR. Transsphenoidal hypophysectomy through the external rhinoplasty approach. Otolaryngol Head Neck Surg 1994;11l:197-200.