Transnasal Transsphenoidal Approach Research Articles

HOW I DO IT: Cushing’s disease—selective adenomectomy via an endoscopic transsphenoidal approach

BackgroundAn ACTH-secreting pituitary adenoma is the most common cause of excessive endogenous glucocorticoid production resulting in Cushing’s Syndrome. A multidisciplinary approach is paramount. Selective adenomectomy is the treatment of choice.MethodEndoscopic transnasal transsphenoidal approach to the tumour, along with techniques for resection, are demonstrated.ConclusionEndoscopic transsphenoidal approaches with its magnified view of the pituitary gland allows precise microsurgical dissection during selective adenomectomy. This technique increases the possibility of proving a gross total resection, leading to clinical and biochemical cure in these patients.

A Rare Case of Clival Hemangioma Simulating Chordoma

AbstractPrimary intraosseous hemangiomas are rare, benign, vascular malformations that account for ∼1% of all primary bone neoplasias. A 59-year-old female patient with unknown comorbidities had a history of headache, visual impairment and dizziness that led to the diagnosis of a clivus tumor. Two resections were attempted through transcranial and transnasal transsphenoidal approach in the last two years in another hospital. The initial MRI scan showed an expansive lesion with T2 hyperintense signal and diffuse, heterogenic contrast enhancement. Clival chordoma was the main diagnostic hypothesis done. A CT scan was performed to evaluate the extent of clival invasion, the sinus anatomy, and the clival destruction - all simulating clival chordoma. The interdisciplinary tumor board decided to proceed with endoscopic endonasal tumor resection. There were no postoperative complications and the histopathological analysis revealed a primary intraosseous haemangioma. Skull base intraosseous hemangiomas are rare entities, with a limited number of case reports found after literature reviews, especially in the clival region. The clinical pattern and imaging characteristics can vary widely according to the tumor extension and development, simulating some other common tumors found at this topography. We present a case report of a clival intraosseous hemangioma presenting as an isolated abducens paresis with a positive outcome after intranasal endoscopic resection after two years of follow-up.

Unusual Presentations of Sellar and Suprasellar Space Occupying Lesion: Our Institutional Experience

AbstractA pituitary abscess (PA) is a rare intracranial lesion. It is a critical disorder caused by an infectious process where purulent material accumulates inside the sella turcica. It occurs either as a primary disease or because of an infection and is associated with poor prognosis. In this article, we share our experience with PA. At our institution, we operated on five cases of pituitary abscess since 2016. All the cases presented with bitemporal hemianopia and headache. None of them had fever. Pituitary hormones were normal except in two patients with a previous history of hypothyroidism. Magnetic resonance imaging (MRI) of the brain showed pituitary macroadenoma. They underwent the endoscopic transnasal transsphenoidal approach. Postoperatively their vision has improved. Endocrine functions were normal in all the patients following surgery. Culture sensitivity was sterile in all the patients. Diagnosis of pituitary abscess is highly difficult before surgery. Hence, the diagnosis should be considered when a patient presents with fever, headache, and signs of pituitary dysfunction and meningeal inflammation. Surgical and medical management leads to a lower mortality rate and a higher probability of hormone function recovery.

Application of a Novel Versatile Mini Posterior Nasoseptal Graft in Endoscopic Transsphenoidal Pituitary Adenoma Surgery.

Skull base reconstruction is a key technique in patients undergoing endoscopic transnasal skull base surgery. Although a pedicled nasoseptal flap (PNSF) is often used to repair large skull base defects with high-flow cerebrospinal fluid leakage, bone exposure of the donor site of the PNSF can result in long-term crusting. To design a novel and versatile mini posterior nasoseptal graft for the reconstruction of defects in the sellar floor or PNSF or pedicled nasoseptal rescue flap (PNSRF) donor site in patients undergoing pituitary adenoma surgery. Patients who underwent pituitary adenoma removal through an endoscopic endonasal approach and repair of a sellar defect or PNSF/PNSRF donor site using the mini posterior nasoseptal graft technique from January 2019 to January 2020 were retrospectively evaluated. Pituitary adenomas were removed using a binostril 4-hand technique through a transnasal transsphenoidal transsellar approach or an expanded transsellar approach. Mini posterior nasoseptal grafts were successfully used in 70 patients who underwent pituitary adenoma removal through an endoscopic transsphenoidal sellar approach. Mini posterior nasoseptal grafts repaired sellar defects in 40 patients and donor site defects of the contralateral PNSF/PNSRF in 30 patients. None of these patients experienced cerebrospinal fluid leakage or major complications. A mini posterior nasoseptal graft is a safe and effective technique for repairing sellar defects after endoscopic transnasal pituitary adenoma surgery. This technique can also be used to repair defects in PNSF/PNSRF donor sites.

Review of first 60 pituitary adenoma cases of a skull base team, one center experience

Background: Endoscopic endonasal transsphenoid approach of pituitary gland is being effectively replacing microscopic approach. This approach need a lot of training and stepwise learning to reach perfection. This study discuss the experience and pitfalls of an evolving skull base team in one institute. Aim of the work: Analysis of first sixty pituitary adenomas patients operated by an evolving skull base teams in one institute, and highlighting modifications introduced in their technique. Methodology: This is a retrospective analytical study of the medical records of first 60 pituitary adenoma patients who had presented to one center and had endoscopic trans-nasal trans-sphenoidal approach by conjoined skull base team. Results: There were 60 cases of pituitary adenoma; 23 males, and 37 females. Mean age were 46 years old. 37 cases (61%) had temporal field defect, 22 cases had visual acuity loss, 41 patients (68%) had nonfunctioning adenomas, and 18% were prolactinomas. Fifty two cases (86.6%) were macroadenoma, and 2 patients (3.3%) were microadenoma. 48 cases (80%) had suprasellar extension, while 19 cases (19%) had parasellar extension. Three cases (5%) were recurrent. Trans-nasal cavity approach was adopted in 58 cases (96.6%). 4 cases needed middle turbinate resection. Mean operative time was 3 hours. Gross total removal of the tumor were achieved in 49 cases (81.6%). Intraoperative CSF leakage occurred in 31 patients (51%). Failure of reconstruction occurred in 4 cases (6.6%). Mean duration of hospital, and ICU stay was 8, 2 days respectively. Postoperative temporary diabetes insipidus occurred in 35 cases (58.3%), 5 of them (8.3%) had permanent DI. Major CNS complications occurred in 2 cases (3%). Conclusion: The more experience gained the more modifications introduced to improve surgical outcome; more gross total resection rate, less morbidity, and mortality rates, less operative time, better quality of life of patients and less time and effort exhaustion of the team work.

Tailored Surgical Access to the Cavernous Sinus and Parasellar Region: Assessment of Cavernous Sinus Entry Corridors and the Periclinoid and Pericavernous Surgical Maneuvers

Lesions involving the cavernous sinus (CS) represent some of the most challenging pathologies of the skull base owing to the dense traversing and surrounding neurovasculature. Extradural exposure and preparation of this region, whether as initial preparation for a combined intra-extradural approach or as the main avenue of surgical exposure, can enlarge surgical corridors and minimize the need for brain retraction in this very confined space. We provide a detailed assessment of the entry corridors to the CS that are available within each approach, the surgical exposure and freedom provided by each of these corridors, and demonstrate how extradural and intradural preparation of these corridors can be used to widen the available working space and facilitate surgery. Pterional, frontotemporal-orbital, frontotemporal-orbitozygomatic, frontotemporal-zygomatic, perilabyrinthine transtentorial, and endoscopic transnasal transsphenoidal approaches were performed on cadaveric heads to access the perisellar and CS regions. Periclinoid maneuvers (extradural cutting of the meningo-orbital band, anterior clinoidectomy, unroofing of the optic canal, opening of the superior orbital fissure, displacement of the extra-annular structures, opening of the annulus of Zinn, and interdural dissection), pericavernous maneuvers (intradural cutting of the distal dural ring, mobilization of the supraclinoid internal carotid artery, opening of the oculomotor porus, and mobilization of cranial nerve (CN) III), peritrigeminal extensions (extradural mobilization of CN V2 [maxillary] and/or V3 [mandibular]), and other surgical maneuvers were performed and evaluated. The CS was divided into 8 anatomical compartments and 9 entry corridors were described, and exposure and freedom were assessed accordingly. Intradurally, the standard unextended pterional, frontotemporal-orbital, and frontotemporal orbitozygomatic transsylvian approaches provided access solely to the parasellar entry corridor into the superior wall of the CS. Expanding these approaches with extradural periclinoid maneuvers allowed for subsequent application of the intradural pericavernous maneuvers and enlargement of the parasellar corridor and exposure of the carotid cave. Extradurally, the frontotemporal-orbital approach could be expanded via application of periclinoid maneuvers, which provided access to the anterior portions of the main lateral wall entry corridors. The frontotemporal-orbitozygomatic approach could also be expanded with periclinoid maneuvers to provide extradural access to all 6 lateral wall entry corridors. The extradural frontotemporal-zygomatic approach only provided exposure following interdural dissection, which allowed for access to the inferolateral entry corridors into the lateral wall. Extradural peritrigeminal extension in the frontotemporal-orbitozygomatic and frontotemporal-zygomatic approaches allows for enlargement of the supramaxillary and pre- and postmandibular corridors. The perilabyrinthine approach to the posterior wall was enlarged with opening of Dorello's canal and the endoscopic transnasal transsphenoidal approach was enlarged with opening of the optic canal. Targeted extradural preparation optimizes exposure and significantly improves access to deep-seated targets by enhancing surgical maneuverability through the unlocking of neurovascular structures and widening of surgical corridors without the need for additional brain retraction.

Sphenoid sinus mucocele: a review

<p class="abstract">Sphenoid sinus mucocele (SSM) is a benign, encapsulated, expansile, locally destructive mass within the sphenoid sinus, filled with mucous and lined by epithelium. The exact etiology of the sphenoid sinus mucocele is still not known. The proximity of the SSM to the orbit and brain may cause morbidity and potential mortality if left without intervention. SSM has varied clinical manifestations. Headache and visual disturbances are common symptoms. Diagnostic nasal endoscopy and computed tomography (CT) scan and/or magnetic resonance imaging (MRI) are important pre-operative investigations. Diagnosis of SSM is done by computed tomography (CT) scan of the nose and paranasal sinus which shows a hypodense cystic lesion in the sphenoid sinus. MRI is helpful to detect the extension of the mucocele to orbit and cranium. Treatment of SSM is surgical which include endoscopic transnasal sphenoidotomy with sufficient removal of anterior and inferior walls of the sphenoid sinus for allowing adequate drainage and to avoid recurrence. The endoscopic approach is a safe and effective method of treatment for SSM with fewer recurrences than an open approach. Marsupialization of the mucocele via transnasal transsphenoidal approach is another option with a good outcome. The literature review for sphenoid sinus mucocele was performed from the database of Pub Med, Medline, Scopus, and Google scholar search with the term sphenoid sinus mucocele. Here, this review article is attempting to discuss the details of the sphenoid sinus mucocele including its history, epidemiology, etiopathology, clinical presentations, investigations, and current treatment. </p>

Abstract No.: ABS2881: Comparison of cardiac indices using two different concentrations of adrenaline wicks during endoscopic trans-sphenoidal pituitary surgery: a prospective randomised observational study

Background & Aims:Trans-nasal trans-sphenoidal approach is preferred for surgical excision of pituitary tumours. Adrenaline is a generally usedvasoconstrictor for instillation or infiltration to decrease bleeding and improve the operative field quality. We aimed to compare the cardiac indices (Flotrac guided) and hemodynamic parameters while using two different doses of adrenaline for instillationMethods:60 ASA I/II patients, aged 18-65 years, undergoing transsphenoidal surgery for pituitary tumours were enrolled and allocatedto two groups. Group 1 received 1:200,000 concentration and Group 2 receiving 1:100,000 concentration of adrenalinetopically using cotton strips for 10-15 minutes. Cardiac indices and haemodynamic parameters were noted at baseline, every 5 minutes for first hour followed by every 10 minutes till the end of the procedure. Blood loss, quality of thefield and any adverse events were notedResults:Significant reductions in cardiac indices (CO, CI) were noted in Group 2 at 60 and 70 minutes of the procedure compared to Group 1. There was no difference in haemodynamic parameters (HR, SBP, DBP, MAP, SPO2,) between the 1:100,000 and 1:200,000 adrenaline groups. However, hypertension and tachycardia were higher following instillation of 1:100,000 adrenaline concentration when compared with the baseline (p<0.005)Conclusion:1:200,000 concentrations of adrenaline for nasal decongestion was associated with lowered cardiac indices compared to1:100,000 concentration. Field quality and usage of rescue drugs were comparable in both the study groups

Relationship of sphenoid sinus to adjacent structures in South India: a retrospective cross sectional study

BackgroundSphenoid sinus is one of the most inaccessible paranasal sinuses. Advent of minimally invasive trans-nasal trans-sphenoidal approach over the past few years has provided an additional armament in the hands of skull-base surgeons to access pathologies adjoining base of skull. Close relationship of vital neurovascular structures with sphenoid sinus and variability of their protrusions into the sinus make these structures more vulnerable to iatrogenic trauma during surgical procedures. Preoperative assessment of such variations is imperative to avoid unintentional damage. The present study is a retrospective study conducted on CT scan records of 140 patients with an aim to evaluate prevalence of vital structures invaginating into sphenoid sinus and their clinical implications. The internal carotid artery (ICA), optic nerve (ON), maxillary nerve (MN), and Vidian nerve (VN) were assessed for protrusion into the sphenoid sinus and their dehiscence. Attachment of septum to protruding structures was also assessed. Data was statistically analyzed in the form of frequency and percentage to evaluate the prevalence of neurovascular invaginations into sphenoid sinus and their clinical implications.ResultsICA invagination was observed in 16% of males and 12% of females with males showing higher frequency on left side. Protrusion of ON was seen in 13% of males and 10% of females with higher prevalence in bilateral category. Twenty-four percent of study population had MN prominences which included 13% of males and 11% of females with higher reflection of bilateral presentation. Highest prevalence of 44% was observed in VN protrusions with equal distribution (22%) among each sex. Majority of these were bilaterally located. Dehiscence of ICA was observed in 9%, ON in 29%, MN in 10%, and VN in 30% of study population. Dehiscence brings these structures closure to sinus mucosa with increased risk of involvement in sinus disease. Septal attachment to ICA and ON was present in 7% and 15% cases respectively.ConclusionPreoperative assessment of anatomical configuration of sphenoid sinus and associated neurovascular structures is mandatory to minimize per-operative complications. This study provides statistical data on anatomical variations in neurovascular structures protruding into the sphenoid sinus, their dehiscence, and septal attachments in South Indian population.

Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores.

Objective This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design This study is a retrospective review. Setting This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien-Dindo grade IV (CDIV) criteria, and mortality. Results Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI ( p = 0.01, R 2 = 0.97) and ASA ( p = 0.04., R 2 = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality ( p = 0.03, R 2 = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35-6.83, p < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.

A Nursing Care Experience of a Patient with an Empty Sella Syndrome Presenting Repetitive Vertigo, Tinnitus and Post-Operative Rhinorrhea

&lt;p&gt;本案例為一名56歲女性因反覆眩暈及耳鳴，經檢查後初步診斷為良性陣發性姿勢性眩暈（Benign Paroxysmal Positional Vertigo, BPPV），接受右耳耳石復位術（Canalith Reposition Procedure），然而，隨著病程進展，接續出現關鍵性的前額眉心處的頭痛及視力模糊的症狀，藉由詳細地病史詢問、身體評估、及相關的檢驗及影像檢查，採用排除及納入相關診斷的鑑別過程，最後確診為蝶鞍空洞症，在詳細地病情解釋後，病人接受經鼻腔內視鏡蝶竇蝶鞍減壓併自體脂肪填充及鼻中隔皮瓣重建手術。不幸地，術後產生腦脊髓液鼻漏的併發症，在及時地重新評估、鑑別診斷及處置，有效的控制併發症避免神經功能惡化，最後病人順利出院，因此引發筆者撰寫動機，期望分享此病例照護經驗，提醒同仁臨床照護病人時需要時刻保持警覺，確保病人回復健康。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;The case in this study is a 56-year-old woman who was initially diagnosed with benign paroxysmal postural dizziness because of repeated vertigo and tinnitus after serial examinations. She underwent reduction of otolith of right ear (Canalith Reposition Procedure). However, her symptoms remained and subsequent symptoms of frontal headache and blurred vision occurred. Although symptoms such as vertigo, tinnitus, and headache are common in Meniere&amp;rsquo;s disease, benign paroxysmal postural vertigo (BPPV), cerebral infarction, etc. eventually we revised the diagnosis to the Empty Sella Syndrome through detailed inquiry of medical history, physical assessment, and image examinations.After well-addressed explanation of the clinical condition, the patient received endoscopic transnasal transsphenoidal approach and packing sella with autologous fat, reconstruction by cartilage and nasal septal flap. Unfortunately, the sequel of cerebrospinal fluid rhinorrhea occurred after the operation. By promptly reassessment, differential diagnosis with proper treatment, the complication was effectively controlled to avoid neurological deterioration, and the patient was discharged without further complication. I sincerely share the experience of this specific case with my colleagues. Keeping vigilant in clinical care of patients to ensure they could return to health.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Development and Application of Three Steps Training Mode for Endoscopic Transnasal Transsphenoidal Approach.

The model of endoscopic transnasal transsphenoidal approach (METTA) were made and the application of the 3-steps training mode in the endoscopic transnasal transsphenoidal approach (ETTA) training was discussed. The plastic skull model was used to make a simple METTA model; the multicolor and multi-material 3D printing technology was used to make a METTA simulation model and the perfusion cadaver head specimen was used as the gold standard training model. Then 3 neurosurgeons evaluated the 3 types of models. Level 1 training group only received perfusion cadaveric head specimen training; level 2 training group with 3D printing METTA model plus cadaver head specimen training, and level 3 training group with simple model, 3D printing model and cadaver head specimen training group. The authenticity of the model and the training effect were evaluated according to the operation time and the damage degree to the surrounding structures. The results showed that perfusion cadaveric head specimens scored the highest in each item. The simplified model was superior to the 3D printing METTA in simulating the shape and elasticity of pituitary tumor tissue. The score of surgical skill training was the same as that of 3D printing METTA. In terms of the training effect, the doctors who had received 3 steps training had the highest score, which was better than the other 2 groups. The application of 3 steps training mode with simple training model, 3D printing model and perfusion cadaver head specimen can improve the effect of ETTA operation training.

Cerebrospinal Fluid Leak in Transnasal Transsphenoidal Surgery for Pituitary Adenoma and its Management

Introduction Over the past few decades endoscopic transnasal transsphenoidal (ETNTS) approach has been practised for excision of pituitary tumours which has minimised the rate of complications and morbidity. However, cerebrospinal fluid (CSF) leak remains a frequent complication requiring efficient management. Various skull-base repair techniques have been described in the literature all along, but there is no universal protocol for the same. Our study aims to determine an ideal strategy for skull-base repair following ETNTS surgery and suggest a protocol at the tertiary centre for the same. Materials and Methods In this prospective study, patients with pituitary adenoma undergoing ETNTS excision from January 2017 to May 2019 were included. Data were collected based on the intraoperative findings of grade of CSF leak following excision, surgical method for skull-base repair, biomaterials used, and recurrence of CSF leak postoperatively and its management. Results A total of 141 patients between 10 to 74 years of age (mean age 42.6) underwent ETNTS excision of pituitary adenoma. Intraoperative CSF leak was observed in 30.5% patients with 14.1% of grade I, 8.5% of grade II and 7.8% of grade III and repair was done with fat closure, multilayer closure and with naso-septal flap, respectively. Postoperative recurrence of CSF leak was found in 2.83% of total cases and 9.3% of patient with intraoperative leak, which were managed appropriately. Overall closure rate was 100% with no further recurrence of CSF leak. Conclusion Surgical repair of skull-base in CSF leak is challenging and requires management in careful and graded fashion for favourable outcome.

A case series and review of the mononostril endoscopic transnasal transsphenoidal approach: Safe and effective in a low resource setting

BackgroundA transnasal transsphenoidal (TNTS) approach can be performed through a binostril or mononostril technique. The binostril technique is generally preferred, however the mononostril may be an underutilized approach with significant benefits. MethodsAll (n = 521) pituitary adenoma transsphenoidal surgeries performed from March 2008 until July 2017 at a university hospital in Indonesia were isolated. The majority (n = 512) were performed through a mononostril approach with no nasal speculum by a single experienced neurosurgeon. A PubMed literature review researching the differences in indications, techniques, and outcomes for both approaches supplements the case series. The mononostril surgical technique is described in detail. ResultsThe average mononostril operating time was 105 min. The most prevalent surgical complications were CSF leak (4.1 %), diabetes insipidus (3.7 %) and cacosmia (2.1 %). Visual field deficits noted in 85 %, 89 % improved. Length of stay was less than 2 days for 90 %, with 13 ICU admissions (average one day). Recurrence rate was 8.2 % at follow up (1–10 years). ConclusionsBased on a literature review, binostril TNTS surgeries have longer operative time and a higher risk of epistaxis. According to our experience, post-operative patient comfort and satisfaction are higher with the monostril approach. Furthermore, this technique is easier to teach, ENT assistance unnecessary, and thus especially advantageous in low resource settings. Our CSF leak and tumor recurrence rates were lower than reported binostril rates in the literature. The mononostril technique is both safe and effective and should be strongly considered for an appropriately pre-selected subset of pituitary adenomas.

Primary intrasellar schwannoma with intratumoral hemorrhage mimicking pituitary apoplexy: A case report

Tumours growing in the sella turcica are mostly pituitary adenomas. We describe a rare case of primary intrasellar schwannoma with intratumoral bleeding. A 38-year-old man presented with headache in association with bilateral supratemporal quadrantopsia. MRI showed an intrasellar mixed signal mass lesion with suprasellar extension. The majority of the pituitary hormones were normal. He was diagnosed as non-functional pituitary adenoma with pituitary apoplexy. Subtotal resection was achieved eventually via an endoscopic transnasal trans-sphenoidal approach. The histopathologic diagnosis was schwannoma. It is the first intrasellar schwannoma with intratumoral hemorrhage in literature to date. It implied that the primary intrasellar schwannoma has potential risk of intratumoral bleeding, which should be considered in the differential diagnoses of sellar lesions.

Outcome After Resection of Craniopharyngiomas and the Important Role of Stereotactic Radiosurgery in Their Management.

Experience with management of craniopharyngiomas (CPH) was evaluated retrospectively. Between 1981 and 2012, 100 patients underwent removal of a CPH (the main surgical group), and an original tumor grading system was applied to these cases. The mean length of follow-up was 121months. Additionally, 17 patients underwent removal of a CPH between 2012 and 2017 (the supplementary surgical group), and in 6 of them, CyberKnife radiosurgery was performed on a residual tumor (in 5cases) or at the time of recurrence (in 1case). In the main surgical group, the gross total resection (GTR) rate was 81%. The early and late disease-specific postoperative mortality rates were 0% and 2%, respectively. Tumor recurrence was never noted after GTR. There was a statistically significant increase in the Karnofsky Performance Scale (KPS) score after surgery. The tumor surgical grade was inversely associated with both the pre- and postoperative KPS scores, and was lower in cases operated on via the transnasal transsphenoidal approach, but was unrelated to the GTR rate. In the supplementary surgical group, the GTR rate was 65%. CyberKnife radiosurgery consistently resulted in tumor shrinkage. GTR is the preferred management option for CPH. The original surgical grading system developed at Tokyo Women's Medical University may be helpful for clinical decision-making. CyberKnife radiosurgery for residual and recurrent CPH is associated with high tumor response rates.

Giant Cell Tumour of Clivus: A Rare Case Report

Giant Cell Tumours (GCT) of the skull is rare, being less than 0.05% of all skeletal tumours. They are usually located in the middle cranial fossa affecting the temporal, sphenoid, petrosal and occipital bone. Clival GCT is rarer and 15 cases are described in the literature. Authors report a case of a female patient aged 20 years, who complained of headache with decrease in vision of left eye. Neurological examination revealed left optic nerve palsy. Laboratory test of Vitamin B12, blood urea, Serum Creatinine, Serum Electrolytes were within normal range. Complete blood count showed mild anaemia. The serum calcium and parathyroid hormones were within normal range. Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) were done, which demonstrated expansile destructive lytic lesion involving sphenoid bone and clivus, reaching upto sellar, parasellar regions, sphenoid sinus and left posterior ethmoid sinus, effacing left optic foramina and posteriorly effacing prepontine cistern. The left internal carotid artery was partially encased by the mass. The tumour was partially removed by endoscopic trans-nasal trans-sphenoidal approach. Histopathology confirmed it as a benign GCT. Surgical treatment of clival GCTs are fraught with complication because of its close proximity to vital structures. High vascularity, potential malignant behaviour, inaccessibility and very few published cases preclude a definite outcome of this lesion. Histopathology is necessary to differentiate various lytic lesion like chordoma, aneurysmal bone cyst, invasive pituitary adenoma, chondrosarcoma and brown tumour (parathyroidism).

Avoiding Complications in Endoscopic Trans-Sphenoidal Surgery for Pituitary Adenoma: A Beginner's Perspective.

Introduction:We aimed to analyze the difficulties and complications experienced while as a beginner in endoscopic transnasal transsphenoidal approach for pituitary adenomas.Materials and Methods:We retrospectively analyzed 83 cases done from June 2016 to August 2019. Navigation-guided endoscopic transnasal transsphenoidal approach was used in all the cases.Results:Gross total tumor removal was achieved in 55 (66.26%) patients. We found that gross total resection rate was inversely proportional to Knosp grading, and the extent of resection was found to have a statistically significant correlation with grade of tumor (P < 0.05). Surgery-related complications were present in 33 of our patients. Nasal complications occurred in six patients: three epistaxis (3.6%) and two hyposmia (2.4%) and one case of septal hematoma (1.2%). Postoperative cerebrospinal fluid leak occurred in six (7.2%) cases, two (2.4%) cases had sinusitis, while two (2.4%) cases had meningitis. There was a very rare case of subarachnoid hemorrhage and one case had sellar hematoma. Endocrinologic complications occurred in 15 (18.07%) patients: anterior pituitary deficiency in five (6.02%) patients, transient diabetes insipidus (DI) in nine (10.84%) patients, and permanent DI in one (1.2%) patient. There was no vascular injury or mortality noted in our study.Conclusion:Endoscopic approach is an effective modality for pituitary surgery; with patience, learning lessons from your own mistakes and by adopting right technique, learning curve can be flattened significantly.

Endoscopic Transnasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Comparison to the Microscopic Approach Cohort by Propensity Score Analysis

Endoscopic Transnasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Comparison to the Microscopic Approach Cohort by Propensity Score Analysis

Long-term olfactory dysfunction after single-nostril endoscopic transnasal transsphenoidal pituitary adenoma surgery

BackgroundOver the past decade, the endoscopic transnasal transsphenoidal approach for pituitary adenomas has been widely adopted among neurosurgeons. However, olfactory disturbances have been observed after this procedure, and few studies on long-term (>6 mo) olfactory disturbance after endoscopic transnasal transsphenoidal pituitary adenoma surgery have been conducted. Although we perform minimally invasive endoscopic surgery, some patients continue to experience hyposmia, with some even experience long-term hyposmia. This impairment results in a considerable loss in quality of life. We present a series of patients who underwent minimally invasive single-nostril TSS for pituitary adenoma, including evaluation of their olfactory function. We further investigated the related risk factors for long-term olfactory dysfunction. MethodsOne hundred sixty-one consecutive patients who met the study criteria underwent the single-nostril endoscopic transsphenoidal approach by the senior author. The Smell Diskettes Olfaction Test was used to evaluate olfactory function. ResultsPostoperative olfactory disturbance in patients treated with endoscopic transnasal TSS is frequent. Of the study population, 67.1% of the patients were hyposmic or anosmic and 14.9% had long-term olfactory dysfunction. We also performed multivariate logistic regression analysis to compare the characteristics of patients with long-term olfactory dysfunction. Nasal symptoms (odds ratio [OR], 6.77) and smoking (OR, 14.77) were associated with long-term olfactory dysfunction after transnasal TSS. ConclusionsSignificant disturbances in olfactory performance occur after single-nostril transnasal TSS for pituitary adenoma. Furthermore, preoperative nasal disease and smoking appear to be risk factors for long-term olfactory dysfunction. Physicians should address clinical findings related to olfactory function and provide appropriate care.