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Transoral approach for large pituitary adenoma using Le Fort I osteotomy with mandibulotomy
Int. Z OralMaxillofac. Surg. 2000; 29:128-130 Printed in Denmark. All rights reserved
Copyright©Munksgaard2000 [nzemationaIJoumdof
Oral& MaxillofacialSurgery ISSN 0901-5027
Pathology
Transoral approach for large pituitary adenoma using Le F0rt I 0ste0t0my with
Yoshinari Myoken 1, Tatsumi Sugata 1, Takeshi Kiriyama 2, Katsuzou Kiya a 1Department of Dentistry and Oral Surgery, Hiroshima Red Cross-Atomic Bomb Survivors Hospital, Hiroshima; 2Department of Dentistry and Oral Surgery, 3Department of Neurosurgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
mandibulotomy A case report Y. Myoken, T. Sugata, T. Kiriyama, K. Kiya." Transoral approach for large pituitary adenoma using Le Fort I osteotomy with mandibulotomy. A case report. Int. J. Oral Maxillofac. Surg. 2000; 29." 128-130. © M u n k s g a a r d , 2000 Abstract. A p a t i e n t is presented with a large p i t u i t a r y a d e n o m a t h a t was successfully treated with a Le F o r t I o s t e o t o m y in c o m b i n a t i o n with mandibulotomy.
Various a p p r o a c h e s have been described to r e a c h the centrally placed clivus a n d midline cranial base t u m o r s , w h i c h are technically difficult to access a n d expose. F o r example, lateral app r o a c h e s have b e e n used, b u t all involve prolonged, a n d at times excessive, ret r a c t i o n o n the b r a i n stem a n d cranial nerves, w h i c h m a y cause postoperative neurological deficits 5'7. Alternatively, a n t e r i o r a p p r o a c h e s t h r o u g h the n a s o p h a r y n x or o r o p h a r y n x with either palatal, maxillary or m a n d i b u l a r splitting m a y provide direct access a n d reduce the risk o f postoperative n e u r o logical deficits a-4,6,x°,12. ARCHER et al. described a transclival a p p r o a c h for the t r e a t m e n t o f basilar a r t e r y a n e u r y s m s using a Le F o r t I osteotomy, w h i c h provided u n p r e c e d e n t e d access to the region o f the clivus in its entirety a n d did n o t cause p r o b l e m s such as soft tissue retraction 2. T h e same a p p r o a c h allows partial or total resection o f midline skull base t u m o r s 12. This t e c h n i q u e
a l o n g with a m a n d i b u l a r split to treat a large pituitary a d e n o m a is described.
Case Report A 54-year-old woman presented with acute onset of headache, associated with slight visual disturbances. Computed tomography of the head revealed a tumor mass involving the clivus. A transmaxillary biopsy was performed and the histopathologic diagnosis was invasive nonfunctioning pituitary adenoma. Her neurological examination was normal and studies revealed normal levels of growth hormone, luteinizing hormone, prolactin, follicle-stimulating hormone and thyroxine. She chose not to undergo surgical treatment but was followed for several months until a year later, when she complained of severe headache and diplopia. Magnetic resonance imaging (MRI) of the head revealed an extremely large, diffuse mass at the cranial base, involving the entire region of the sella and sphenoid sinus, with bilateral extension into the cavernous sinus. Suprasellar extension into the region of the hypothalamus was observed (Fig. 1).
Key words: Le Fort I osteotomy; mandibulotomy; neurosurgical procedure; skull base neoplasm. Accepted for publication 18 November 1999
Surgery was now thought to be necessary. Anesthesia was administered via oral intubation because she refused a tracheotomy. A midline mandibulotomy was first performed to prepare space for an oral endotracheal tube (Fig. 2). A L e Fort I osteotomy was performed to displace the maxilla downwards. The downwards displaced maxilla allowed optimal access to the clivus. The inferior turbinates were excised and the nasal septum was removed piecemeal to expose the roof of the nasopharynx and the clivus. Self-retaining retractors were inserted to keep the maxilla displaced downwards and a large box-like space was created (Fig. 2). The tumor was then resected by the neurosurgeons, after which the maxilla and mandible were repositioned and fixed with miniplates applied. A nasogastric tube was inserted for postoperative feeding. Postoperatively, the patient's headache and diplopia resolved and her wounds healed satisfactorily without CSF leakage or meningitis. She had no other neurological deficits. The cosmetic result was excellent and there were no significant problems related to malocclusion. MRI of the head showed semitotal removal of the tumor (Fig. 3). The patient
Le Fort I osteotomy with mandibulotomy to approach pituitary adenoma
129
ported that single fragment maxillotomy does not always allow adequate access to the clivus, especially to the lower clivus6,8. The use of a mandibulotomy, however, provided sufficient space for an oral endotracheal tube and allowed sufficient displacement of the maxilla 11. The surgical access extended from the pituitary fossa to the arch of the atlas and provided good exposure of the large pituitary adenoma. The technique described may avoid palatal dysfunction resulting in a nasality of the voice, dysphagia, nasal regurgitation and oronasal fistulas, as compared to the midpalatal splitting of the downfractured maxilla which may also provide good access to the entire clivus6'8'9.
Fig. 1. Preoperative coronal MRI demonstrates large midline tumor invading clivus with suprasellar extension.
Fig. 2. Midline mandibulotomy provides space for an oral endotracheal tube (arrowheads). Self-retaining retractors are inserted to keep the maxilla displaced downwards and a large box-like space is created.
received postoperative local radiation therapy (46 Gy in total). At present, three years postoperatively, she is in good condition.
Discussion
Surgery is the treatment of choice for giant invasive pituitary adenomas which involve the sella and parasellar regions, along with superior suprasellar extension and inferior invasion of the clivus1'12. The object is to achieve maximal tumor resection but to preserve function with minimal visible scarring
Fig. 3. Postoperative coronal MRI reveals semitotal resection of tumor.
Acknowledgments. We thank T. Nishida, Y. Moriki and N. Nakajuma for technical assistance.
and deformity. There are essentially three potential transoral approaches for midline skull base tumors 6. The first is a transmandibular approach using a parasagittal labiomandibulotomy, which provides access to the anterior spine from C1 to C4, but leaves visible external scarring3. If additional exposure of the clivus is required, the mandibulotomy should be combined with midline palatal division, which may cause velopharyngeal incompetence6. The second is a transmaxillary approach using a hemimaxillotomy which allows good exposure of the middle compartment of the skull base from the roof of the sphenoid to C5, but leaves facial scarring4. This technique, however, precludes a midline approach which neurosurgeons may find disadvantageous6. Thirdly, a transmaxillary approach using a Le Fort I osteotomy is possible, which provides excellent access extending from the sella to the arch of the atlas and to the lateral recesses on either side without soft tissue retraction 12. The major drawback with the Le Fort I osteotomy, however, is the necessity of turbinectomy and damage to the nasal septum. Selection of an appropriate access technique depends on the anatomical location of the skull base tumour. Since the large midline pituitary adenoma involved the entire clivus and extended suprasellarly, a Le Fort I osteotomy was chosen. Although this technique was originally described to provide good access to the entire clivus, it has been r e -
References
1. ANSON JA, SEGALMN, BALDWINNG, NEALD. Resection of giant invasivepituitary tumors through a transfacial approach. Technical case report. Neurosurgery 1995: 37: 541-6. 2. ARCHERDJ, YOUNGS, UTTLEYD. Basilar aneurysms: a new transclival approach via maxillotomy. J Neurosurg 1987: 67: 54-8. 3. BILLER HF, LAWSONW. Anterior mandibular splitting approach to the skull base. Ear Nose Throat J 1986: 65: 13141. 4. COCKE EW, ROBERTSONJH, CROOKJR The extended maxillotomy and subtotal maxillectomy for excision of skull base tumors. Arch Otolaryngol Head Neck Surg 1990: 116: 92-104. 5. FISCH U, PILLSBURY HC. Infratemporal
fossa approach to lesions in the temporal bone and base of skull. Arch Otolaryngol 1979: 105: 99-107. 6. GRXMEPD, HASI~LL R, ROBERTSON I, GULLANR. Transfacial access for neurosurgical procedures. An extended role for the maxillofacial surgeon. I. The upper cervical spine and clivus. Int J Oral Maxillofac Surg 1991: 20:285 90. 7. HOLLIDAG MJ. Lateral transtemporalsphenoid approach to the skull base. Ear Nose Throat J 1986: 65: 153-62. 8. HOLTONJB. Surgical approaches for tumors and conditions of the anterior cranial base and the middle cranial fossa. Oral Maxillofac Surg Clin N Am 1997: 9: 451-76. 9. JONES DC, HAYTER JR VAUGHANED, FINDLAY GFG. Oropharyngeal morbidity following transoral approaches to
the upper cervical spine. Int J Oral Maxillofac Surg 1998: 27:295 8. 10. PAPELID, KENNEDYDW, CO~ E. Sub-
130
Myoken et al.
labial transseptal transsphenoidal approach to the skull base. Ear Nose Throat J 1986: 65: 107-16. 11. SALrNSPC. The trans nas0-orbito-maxillary approach to the anterior and middle
skull base. Int J Oral Maxillofac Surg 1998: 27:53 7. 12. UTrLEY D, MOORE A, ARCHERDJ. Surgical management of midline skull-base tumors. A new approach. J Neurosurg 1989: 71: 705-10.
Address:
Yoshinari Myoken, PhD, DDS Department of Dentistry and Oral Surgery Hiroshima Red Cross-Atomic Bomb Survivors Hospital 1-9-6, Senda-Machi, Naka-ku Hiroshima 730-0052 Japan Fax." +81 82 246 0676 e-mail: [email protected]
Copyright©Munksgaard2000 [nzemationaIJoumdof
Oral& MaxillofacialSurgery ISSN 0901-5027
Pathology
Transoral approach for large pituitary adenoma using Le F0rt I 0ste0t0my with
Yoshinari Myoken 1, Tatsumi Sugata 1, Takeshi Kiriyama 2, Katsuzou Kiya a 1Department of Dentistry and Oral Surgery, Hiroshima Red Cross-Atomic Bomb Survivors Hospital, Hiroshima; 2Department of Dentistry and Oral Surgery, 3Department of Neurosurgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
mandibulotomy A case report Y. Myoken, T. Sugata, T. Kiriyama, K. Kiya." Transoral approach for large pituitary adenoma using Le Fort I osteotomy with mandibulotomy. A case report. Int. J. Oral Maxillofac. Surg. 2000; 29." 128-130. © M u n k s g a a r d , 2000 Abstract. A p a t i e n t is presented with a large p i t u i t a r y a d e n o m a t h a t was successfully treated with a Le F o r t I o s t e o t o m y in c o m b i n a t i o n with mandibulotomy.
Various a p p r o a c h e s have been described to r e a c h the centrally placed clivus a n d midline cranial base t u m o r s , w h i c h are technically difficult to access a n d expose. F o r example, lateral app r o a c h e s have b e e n used, b u t all involve prolonged, a n d at times excessive, ret r a c t i o n o n the b r a i n stem a n d cranial nerves, w h i c h m a y cause postoperative neurological deficits 5'7. Alternatively, a n t e r i o r a p p r o a c h e s t h r o u g h the n a s o p h a r y n x or o r o p h a r y n x with either palatal, maxillary or m a n d i b u l a r splitting m a y provide direct access a n d reduce the risk o f postoperative n e u r o logical deficits a-4,6,x°,12. ARCHER et al. described a transclival a p p r o a c h for the t r e a t m e n t o f basilar a r t e r y a n e u r y s m s using a Le F o r t I osteotomy, w h i c h provided u n p r e c e d e n t e d access to the region o f the clivus in its entirety a n d did n o t cause p r o b l e m s such as soft tissue retraction 2. T h e same a p p r o a c h allows partial or total resection o f midline skull base t u m o r s 12. This t e c h n i q u e
a l o n g with a m a n d i b u l a r split to treat a large pituitary a d e n o m a is described.
Case Report A 54-year-old woman presented with acute onset of headache, associated with slight visual disturbances. Computed tomography of the head revealed a tumor mass involving the clivus. A transmaxillary biopsy was performed and the histopathologic diagnosis was invasive nonfunctioning pituitary adenoma. Her neurological examination was normal and studies revealed normal levels of growth hormone, luteinizing hormone, prolactin, follicle-stimulating hormone and thyroxine. She chose not to undergo surgical treatment but was followed for several months until a year later, when she complained of severe headache and diplopia. Magnetic resonance imaging (MRI) of the head revealed an extremely large, diffuse mass at the cranial base, involving the entire region of the sella and sphenoid sinus, with bilateral extension into the cavernous sinus. Suprasellar extension into the region of the hypothalamus was observed (Fig. 1).
Key words: Le Fort I osteotomy; mandibulotomy; neurosurgical procedure; skull base neoplasm. Accepted for publication 18 November 1999
Surgery was now thought to be necessary. Anesthesia was administered via oral intubation because she refused a tracheotomy. A midline mandibulotomy was first performed to prepare space for an oral endotracheal tube (Fig. 2). A L e Fort I osteotomy was performed to displace the maxilla downwards. The downwards displaced maxilla allowed optimal access to the clivus. The inferior turbinates were excised and the nasal septum was removed piecemeal to expose the roof of the nasopharynx and the clivus. Self-retaining retractors were inserted to keep the maxilla displaced downwards and a large box-like space was created (Fig. 2). The tumor was then resected by the neurosurgeons, after which the maxilla and mandible were repositioned and fixed with miniplates applied. A nasogastric tube was inserted for postoperative feeding. Postoperatively, the patient's headache and diplopia resolved and her wounds healed satisfactorily without CSF leakage or meningitis. She had no other neurological deficits. The cosmetic result was excellent and there were no significant problems related to malocclusion. MRI of the head showed semitotal removal of the tumor (Fig. 3). The patient
Le Fort I osteotomy with mandibulotomy to approach pituitary adenoma
129
ported that single fragment maxillotomy does not always allow adequate access to the clivus, especially to the lower clivus6,8. The use of a mandibulotomy, however, provided sufficient space for an oral endotracheal tube and allowed sufficient displacement of the maxilla 11. The surgical access extended from the pituitary fossa to the arch of the atlas and provided good exposure of the large pituitary adenoma. The technique described may avoid palatal dysfunction resulting in a nasality of the voice, dysphagia, nasal regurgitation and oronasal fistulas, as compared to the midpalatal splitting of the downfractured maxilla which may also provide good access to the entire clivus6'8'9.
Fig. 1. Preoperative coronal MRI demonstrates large midline tumor invading clivus with suprasellar extension.
Fig. 2. Midline mandibulotomy provides space for an oral endotracheal tube (arrowheads). Self-retaining retractors are inserted to keep the maxilla displaced downwards and a large box-like space is created.
received postoperative local radiation therapy (46 Gy in total). At present, three years postoperatively, she is in good condition.
Discussion
Surgery is the treatment of choice for giant invasive pituitary adenomas which involve the sella and parasellar regions, along with superior suprasellar extension and inferior invasion of the clivus1'12. The object is to achieve maximal tumor resection but to preserve function with minimal visible scarring
Fig. 3. Postoperative coronal MRI reveals semitotal resection of tumor.
Acknowledgments. We thank T. Nishida, Y. Moriki and N. Nakajuma for technical assistance.
and deformity. There are essentially three potential transoral approaches for midline skull base tumors 6. The first is a transmandibular approach using a parasagittal labiomandibulotomy, which provides access to the anterior spine from C1 to C4, but leaves visible external scarring3. If additional exposure of the clivus is required, the mandibulotomy should be combined with midline palatal division, which may cause velopharyngeal incompetence6. The second is a transmaxillary approach using a hemimaxillotomy which allows good exposure of the middle compartment of the skull base from the roof of the sphenoid to C5, but leaves facial scarring4. This technique, however, precludes a midline approach which neurosurgeons may find disadvantageous6. Thirdly, a transmaxillary approach using a Le Fort I osteotomy is possible, which provides excellent access extending from the sella to the arch of the atlas and to the lateral recesses on either side without soft tissue retraction 12. The major drawback with the Le Fort I osteotomy, however, is the necessity of turbinectomy and damage to the nasal septum. Selection of an appropriate access technique depends on the anatomical location of the skull base tumour. Since the large midline pituitary adenoma involved the entire clivus and extended suprasellarly, a Le Fort I osteotomy was chosen. Although this technique was originally described to provide good access to the entire clivus, it has been r e -
References
1. ANSON JA, SEGALMN, BALDWINNG, NEALD. Resection of giant invasivepituitary tumors through a transfacial approach. Technical case report. Neurosurgery 1995: 37: 541-6. 2. ARCHERDJ, YOUNGS, UTTLEYD. Basilar aneurysms: a new transclival approach via maxillotomy. J Neurosurg 1987: 67: 54-8. 3. BILLER HF, LAWSONW. Anterior mandibular splitting approach to the skull base. Ear Nose Throat J 1986: 65: 13141. 4. COCKE EW, ROBERTSONJH, CROOKJR The extended maxillotomy and subtotal maxillectomy for excision of skull base tumors. Arch Otolaryngol Head Neck Surg 1990: 116: 92-104. 5. FISCH U, PILLSBURY HC. Infratemporal
fossa approach to lesions in the temporal bone and base of skull. Arch Otolaryngol 1979: 105: 99-107. 6. GRXMEPD, HASI~LL R, ROBERTSON I, GULLANR. Transfacial access for neurosurgical procedures. An extended role for the maxillofacial surgeon. I. The upper cervical spine and clivus. Int J Oral Maxillofac Surg 1991: 20:285 90. 7. HOLLIDAG MJ. Lateral transtemporalsphenoid approach to the skull base. Ear Nose Throat J 1986: 65: 153-62. 8. HOLTONJB. Surgical approaches for tumors and conditions of the anterior cranial base and the middle cranial fossa. Oral Maxillofac Surg Clin N Am 1997: 9: 451-76. 9. JONES DC, HAYTER JR VAUGHANED, FINDLAY GFG. Oropharyngeal morbidity following transoral approaches to
the upper cervical spine. Int J Oral Maxillofac Surg 1998: 27:295 8. 10. PAPELID, KENNEDYDW, CO~ E. Sub-
130
Myoken et al.
labial transseptal transsphenoidal approach to the skull base. Ear Nose Throat J 1986: 65: 107-16. 11. SALrNSPC. The trans nas0-orbito-maxillary approach to the anterior and middle
skull base. Int J Oral Maxillofac Surg 1998: 27:53 7. 12. UTrLEY D, MOORE A, ARCHERDJ. Surgical management of midline skull-base tumors. A new approach. J Neurosurg 1989: 71: 705-10.
Address:
Yoshinari Myoken, PhD, DDS Department of Dentistry and Oral Surgery Hiroshima Red Cross-Atomic Bomb Survivors Hospital 1-9-6, Senda-Machi, Naka-ku Hiroshima 730-0052 Japan Fax." +81 82 246 0676 e-mail: [email protected]