Transnasal Transsphenoidal Approach Research Articles

First Stage in Predicative Measure for Transnasal Transsphenoidal Approach to Petrous Apex Cholesterol Granuloma

Objectives: This is the first in a three-stage study, looking at the feasibility of the transsphenoidal approach to the petrous apex (PA) cholesterol granuloma (CG) based on what we refer to as the petrous angle. This is the angle centered at the vomer, extending between the medial aspect of the petrous internal carotid artery (ICA) and the occipital protuberance. The aim of this study is to determine the average petrous angle in a population of normal computed tomography (CT) scans.

Second Stage in Predicative Measure for Transnasal Transsphenoidal Approach to Petrous Apex Cholesterol Granuloma

Objective: This study is the second stage in a three-stage study, which aimed to identify the narrowest petrous angle that would allow a transsphenoidal approach for treatment of cholesterol granulomas based on our operative experience.

Endoscopic Trans-Nasal Trans-Sphenoidal (TNTS) Approach For Pituitary Adenomas: Our Experience

Advances in optics, miniaturization, and endoscopic instrumentation have revolutionized surgery in the past decade. Current progress in the field of endoscopy promises to further this evolution: endoscopic telescopes and instruments have improved upon the optical and technical limitations of the microscope, and require an even less invasive approach to the sella. Pituitary surgery is traditionally within the realm of the neurosurgeon. However, since the reintroduction of the transseptal transsphenoidal approach and endoscopic transnasal transsphenoidal approach to the sella turcica for resection of pituitary adenoma, otolaryngologists have been active partners in the surgical management of these patients. Otolaryngologists have lent their expertise in nasal and sinus surgery, assisting the neurosurgeon with the operation. The otolaryngologist has the advantage of familiarity with the techniques and instruments used to gain exposure of the sella turcica by transnasal approach. Hence, the otolaryngologist provides the exposure, and the neurosurgeon resects the tumour. Such collaboration has resulted in decreased rates of complication and morbidity. We hereby discuss our experience of treating 54 cases of pituitary tumour by endoscopic transnasal approach at our hospital.

Endoscopic Extracapsular Removal of Pituitary Adenoma: The Importance of Pretreatment of an Adjacent Unruptured Internal Carotid Artery Aneurysm

The presence of an intracranial aneurysm together with a pituitary adenoma presents tremendous risk of subarachnoid hemorrhage, during transsphenoidal surgery, particularly when the aneurysm lies near the operative field. A left supraclinoid internal carotid artery aneurysm and a clinically nonfunctioning pituitary adenoma coexisted in a 57-year-old woman. Initially, the aneurysm was treated by endovascular coil placement, and then the patient underwent pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach. Pseudocapsule-based extracapsular total resection was safely performed, because of the extirpated risk of rupture of the coil-treated aneurysm. Recently, transsphenoidal pseudocapsule-based extracapsular resection approach for pituitary adenomas provides a more effective and safe alternative compared to the traditional intracapsular one because of its higher tumor removal and remission rates and lower recurrence rate. Compared with conventional subcapsular removal, pseudocapsule-based extracapsular resection has more risks of aneurysmal rupture that is located adjacent to pituitary adenoma. Thus, in a patient having a cerebral aneurysm with the proximity to the operative field, the cerebral aneurysm should be first treated with endovascular coil placement or direct surgical procedure; subsequently, pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach should be performed.

Neurocysticercosis, Meningioma, and Silent Corticotroph Pituitary Adenoma in a 61-Year-Old Woman

We report here the case of a 61-year-old woman who presented with hydrocephalus and cystic and solid lesions in sella turcica, suprasellar areas, and third ventricle. After ventriculoperitoneal shunt she developed cognitive changes and the cystic lesions enlarged. Magnetic resonance imaging (MRI) demonstrated multiple cysts and a solid lesion in the sella and around the anterior clinoid process. With diagnosis of neurocysticercosis she underwent craniotomy. Pathologic examination documented two different lesions: viable and dead cysticerci with inflaming infiltration and a left anterior clinoidal meningioma. At the second surgery, six weeks later via transnasal transsphenoidal approach a silent corticotroph pituitary adenoma was removed which was studied by histology, immunohistochemistry, and electron microscopy. To our knowledge, the occurrence of these three different lesions in the sellar area was not described before.

Intraoperative MRI for transphenoidal procedures: Short-term outcome for 100 consecutive cases

Background The majority of pituitary lesions are benign and can be cured with complete surgical resection. However, the transsphenoidal technique (the most common approach for pathology in this region) is limited by poor visualization and anatomical constraints. This can lead to incomplete tumor resection and thus increased recurrence rates. The use of iMRI during these procedures offers the advantage of radiographic confirmation during the procedure and may improve extent of resection. We reviewed our experience with this technology in 100 consecutive cases and compared the outcomes to published results. Methods 100 patients were treated via transnasal transsphenoidal approach using the GE Signa SP 0.5 Tesla (double doughnut design) iMRI system between July 2002 and August 2009 and followed prospectively. Intraoperative findings, imaging results, postoperative MRI and clinical outcome were evaluated to determine the extent of tumor resection, monitor for recurrence and determine outcome. Results There were 100 patients studied, 81 macroadenomas, 9 microadenomas, and 10 other pathological diagnosis. The average extent of resection was 96% with gross total resection based on iMRI in 76 patients (76%). Four patients (4%) all with macroadenomas greater than 4 cm experienced major perioperative complications (hydrocephalus 2, thalamic infarct 1, major arterial bleeding 1), six patients (6%) developed post-operative CSF leaks, one patient (1%) had post-operative worsening of visual fields, and five patients (5%) had abdominal fat graft infections. Nine patients (9%) including five with known residual tumor required post-operative adjuvant treatment during the follow-up period secondary to either disease progression or failure to achieve endocrinological cure. Conclusions iMRI-guided transsphenoidal pituitary surgery provides the surgeon with immediate radiographic feedback during the procedure and aides in overcoming the limitations in direct visualization during such procedures. As a result of this it may enable surgeons to perform such procedures with fewer complications and increased rate of gross total resection. However, the impact of this technology on long-term tumor control still needs to be determined with further follow-up.

Technical Notes on Endoscopic Transnasal Transsphenoidal Approach for Clival Chondrosarcoma

Although there are various operative approaches for clival tumors, a transsphenoidal approach is one of choices when the main tumor extention is in an anterior-posterior direction with a slight lateral extension. However, this approach sometimes provides only narrow and deep operative field. Recently, endoscopic transnasal transsphenoidal approach is quite an effective approach for clival tumors because of the improvement of surgical instruments, image guidance systems, and techniques and materials of wound closure. In this paper, we describe the effectiveness, technical problems, and solution of this approach based on our experiences with two clival chondrosarcomas that was removed by endoscopic transnasal transsphenoidal approach.

Repair of CSF Leaks in the Lateral Recess of the Sphenoid Sinus Transsphenoid vs. Transpterygoid Approach

Introduction: Cerebrospinal fluid (CSF) leaks involving the lateral extension of the sphenoid sinus create unique challenges for the endoscopic approach. Such defects are typically inaccessible through a typical transethmoid or transsphenoid corridor. Recently, an endoscopic transpterygoid approach to the lateral sphenoid recess has been adopted and reported by several groups. However, this technique requires extended surgical time and can put the sphenopalatine ganglion and maxillary division of the trigeminal nerve at risk. In the current study we detail our experience with an extended transnasal transsphenoidal approach to lateral sphenoid sinus CSF leaks and meningoencephaloceles.

A Case of Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea Associated with Primary Empty Sella Syndrome

Received July 1, 2011 Revised August 4, 2011 Accepted August 6, 2011 Address for correspondence Seok-Won Park, MD, PhD Department of OtorhinolaryngologyHead and Neck Surgery, Dongguk University College of Medicine, Ilsan Hospital, 814 Siksa-dong, Ilsandong-gu, Goyang 410-773, Korea Tel +82-31-961-7430 Fax +82-31-961-7427 E-mail sw43857@dumc.or.kr The empty sella syndrome is defined as the herniation of a subarachnoid space within the sella, with a flat-pressed pituitary gland accompanying hormonal problems or cerebrospinal fluid (CSF) rhinorrhea. CSF rhinorrhea is rare in the primary empty sella syndrome. We report a case of primary empty sella syndrome with CSF rhinorrhea in a 57 year-old woman. The CSF rhinorrhea was treated successfully by endoscopic transnasal transsphenoidal approach. Korean J Otorhinolaryngol-Head Neck Surg 2011;54:727-30 Key WordsZZEmpty sella syndrome ᆞCerebrospinal fluid rhinorrhea ᆞEndoscopic surgery.

Transphenoidal endoscopic approaches for pituitary adenomas: a critical review of our experience

BackgroundThe surgical approach to the pituitary fossae has evolved from transcranial to sublabial and transseptal microscopic ones, up to the current transsphenoidal endoscopic approach. ObjectivesTo present our experience in the transnasal transsphenoidal approach for pituitary adenomas and the modifications introduced to improve tumoral resection and to lower iatrogenia. Material and methodsOver nine years, we operated on 37 patients with pituitary adenomas using the transsphenoidal endoscopic approach. We utilised optical lens of 0° (approach) and 30° (adenoma resection), optic navigator, surgical instruments for nasal endoscopic and pituitary surgery. During the neurosurgical step, the endoscope was fixed by an articulated arm. We acceded to the pituitary fossae by a bilateral sphenoidotomy. ResultsSphenoid pneumatisation was sufficient in all the patients. The more common postoperative complications were diabetes insipidus and endocrinology deficiencies. Postoperative rhinoliquorrhea affected only one patient. No alterations of nasal fossae were observed. Mean patient hospitalisation was five days. ConclusionsTranssphenoidal endoscopic approach guided by navigator gives significant advantages: Shorter operating time and fewer complications, greater safety and preservation of the nasal passages. Resecting the sphenoidal rostrum and a fragment of adjacent nasal septum improves surgical instrument management into the pituitary fossae and therefore adenoma resection. Endoscope fixation stabilises the vision and allows the second surgeon to help more effectively.

Abordajes transesfenoidales endoscópicos de los adenomas hipofisarios: una revisión crítica de nuestra experiencia

Background The surgical approach to the pituitary fossae has evolved from transcranial to sublabial and transseptal microscopic ones, up to the current transsphenoidal endoscopic approach. Objectives To present our experience in the transnasal transsphenoidal approach for pituitary adenomas and the modifications introduced to improve tumoral resection and to lower iatrogenia. Material and methods Over nine years, we operated on 37 patients with pituitary adenomas using the transsphenoidal endoscopic approach. We utilised optical lens of 0° (approach) and 30° (adenoma resection), optic navigator, surgical instruments for nasal endoscopic and pituitary surgery. During the neurosurgical step, the endoscope was fixed by an articulated arm. We acceded to the pituitary fossae by a bilateral sphenoidotomy. Results Sphenoid pneumatisation was sufficient in all the patients. The more common postoperative complications were diabetes insipidus and endocrinology deficiencies. Postoperative rhinoliquorrhea affected only one patient. No alterations of nasal fossae were observed. Mean patient hospitalisation was five days. Conclusions Transsphenoidal endoscopic approach guided by navigator gives significant advantages: Shorter operating time and fewer complications, greater safety and preservation of the nasal passages. Resecting the sphenoidal rostrum and a fragment of adjacent nasal septum improves surgical instrument management into the pituitary fossae and therefore adenoma resection. Endoscope fixation stabilises the vision and allows the second surgeon to help more effectively.

Olfactory improvement in acromegaly after transnasal transsphenoidal surgery

The direct transnasal transsphenoidal approach to the sellar region has become a widely adopted surgical procedure among neurosurgeons and ear, nose, and throat specialists. Nasal complications and their incidence have been investigated, but a systematic testing of olfactory disturbance has not previously been performed. Considering that the sense of smell is deeply anchored and interwoven within the CNS, and that its impairment implies a considerable loss in quality of life, surgical practice should aim at its preservation. In this retrospective study, pre- and postoperative olfactory performance, nasal airway passage, septal perforation, and epistaxis were assessed in 96 patients who underwent direct transnasal transsphenoidal microsurgery at the authors' department between January 2007 and August 2009. Olfactory performance was assessed using the Sniffin' Sticks test and/or the Zürcher Geruchstest. After surgery, 47 (49%) of 96 patients improved, 34 (35%) of 96 deteriorated, and 15 (16%) of 96 presented with unchanged olfactory performance. With respect to the underlying pathological entity, the authors noticed a remarkable difference between patients with acromegaly (23 cases) and all other patients (73 cases). Fifteen (65%) of 23 patients with acromegaly improved (others 44%), only 3 (13%) of 23 deteriorated (others 42%), and 5 (22%) of 23 remained unchanged (others 14%) in their ability to distinguish odors. This illustrates a significant shift toward improved postoperative olfactory performance (cross-tabulation, Fisher exact test; p = 0.028) in patients with acromegaly. In nasal breathing, 77 (80%) of 96 patients noticed no change, 11 (12%) of 96 improved, and 8 (8%) of 96 worsened postoperatively. Of the 11 patients with improved breathing, 6 (55%) had acromegaly. Improved nasal airway patency was more frequent in patients with acromegaly (cross-tabulation, Fisher exact test; p = 0.002). The data provide the first significant evidence for improvement in olfactory performance in patients with acromegaly after transsphenoidal surgery (TSS) of growth hormone-producing adenomas. Furthermore, postoperative olfactory disturbance in patients treated with transnasal TSS is more frequent than previously reported. Nevertheless, recurrent transnasal TSS can be performed successfully, even multiple times, and does not involve a higher risk of nasal complications.

Managing primary pituitary tumours: Assessments and complications

Specific treatment for primary pituitary tumours and the diseases they cause will depend on the tumour type, but most patients require surgery which is most commonly performed via a transnasal transsphenoidal approach. Postoperative complications include impairment of visual acuity, visual field defects, diabetes insipidus, epistaxis, and cerebrospinal fluid leak. The nursing assessments and management of each of the complications will be discussed in this article.

A new technique for management of intercavernous sinus bleeding with titanium clips in transsphenoidal surgery

Venous bleeding induced by intercavernous sinus injury during sellar dural opening is a challenging intraoperative complication and is difficult to treat in transsphenoidal surgery. To date, few studies concerning the management of intercavernous sinus bleeding have been reported. Our aim was to assess the clinical outcomes of a new hemostasis technique utilizing nonpenetrating titanium clips for management of intercavernous sinus bleeding. From January 2007 to July 2008, 242 pituitary tumors were operated using a transnasal transsphenoidal approach. A new technique involving a specially devised clip applier and titanium clips was used to control venous bleeding in 13 (5.4%) patients who exhibited a prominent intercavernous sinus. All patients were evaluated clinically and radiologically at 9 to 24 months, and postoperative magnetic resonance imaging (MRI) was performed at 3 to 18 months. No operation was interrupted or aborted due to ineffective bleeding control, and there was no delayed bleeding noted as a complication. No complications related to the use of the device occurred. Imaging studies revealed no evidence of significant clip artifact. Our surgical experience has revealed that this new hemostasis technique can be a safe, rapid and effective method for control of intercavernous sinus bleeding during sellar dural opening in transsphenoidal surgery. However, a further prospective study to evaluate this method more fully is planned.

Resection of Tumors of the Clivus by a Transnasal Trans-sphenoidal Approach

Objective: In this study, we report our experience with the transnasal trans-sphenoidal approach for the resection of tumors of the clivus.

Endoscopic Trans-sphenoidal Approach to Craniopharyngiomas

Introduction: The current mainstay of therapy for craniopharyngiomas is surgical resection. Techniques for resection have evolved to include a transnasal trans-sphenoidal endoscopic approach. The goals of this approach are to achieve complete resection while reducing the high mortality associated with craniotomy, and also to increase patient quality of life postoperatively by sparing the surrounding neurovascular and endocrine structures.

Assessment of the Extent of Resection of Pituitary Adenomas via the Trans-sphenoidal Approach Using a Movable Ceiling Mounted Intraoperative MRI: A 1-Year Experience

Objective: To assess the extent of resection of pituitary adenomas via the transnasal trans-sphenoidal endoscopic approach during 1 year of experience using a movable ceiling mounted intraoperative MRI (iMRI) device.

Sphenoid sinus aspergillosis simulating pituitary tumor in immunocompetent patient

Aspergillosis of the sphenoid sinus is rare in immunocompetent patients. It may be mistaken for a sellar region tumor. A 65-year-old, human immunodeficiency virus-negative man presented with a 3-week history of cranial nerve III paresis and visual deterioration. The patient had a long-term history of tobacco snuff abuse. CT scans and MRI demonstrated a space-occupying lesion of the sellar and sphenoid sinus region. Presumptive diagnosis of pituitary macroadenoma was made and the patient was operated on via a transnasal–transsphenoidal approach. After the sphenoid sinus was opened, a yellow-brownish gluey material with crumbly debris extruded and was aspirated. The dura was intact. Histopathology revealed numerous Aspergillus hyphae without tissue invasion. Postoperatively, the cranial nerve III paresis resolved in a few days and visual acuity improved. Sphenoid sinus aspergillosis should be included in the differential diagnosis of sellar region processes, even in immunocompetent patients. Early diagnosis and transsphenoidal removal provides good results without the need for systemic antifungal therapy in non-invasive aspergillosis.

Analysis of Transnasal Endoscopic versus Transseptal Microscopic Approach for Excision of Pituitary Tumors

The traditional method of pituitary tumor excision is transseptal microscopic excision; however, the transnasal transsphenoidal endoscopic approach has shown comparable results with the transseptal microscopic approach at some institutions. The objective of this study is to compare the two types of sellar and parasellar mass resection: transnasal transsphenoidal endoscopic excision versus transseptal microscopic excision. A retrospective cohort analysis was performed on subjects who were referred to a tertiary hospital for surgical management of sellar or parasellar masses. The two groups of patients either underwent a transnasal endoscopic approach with endoscopic excision or transseptal microscopic excision. Demographics, tumor characteristics, operative details, length of hospital stay, intraoperative and postoperative complications, level of postoperative pain, recurrence rate, use of computed tomography (CT) image guidance, and length of follow-up were gathered. The data between the two groups were then compared. The analysis included 19 subjects who underwent endoscopic excision and 29 subjects who underwent transseptal microscopic excision. Null macroadenoma was the most common sellar mass followed by prolactinoma. There were no statistical differences in rates of perioperative complications and suprasellar or cavernous sinus invasion. Patients who underwent an endoscopic approach had shorter operative times, lower estimated blood loss, less lumbar drain use, less pain, and a shorter postoperative hospital stay (p < 0.05). The two approaches show similar intraoperative characteristics and immediate complication rates. Transnasal transsphenoidal endoscopic excision is a reasonable alternative to the traditional method of sellar mass excision.

Endoscopic Transsphenoidal Surgery of Chordoma

Clinical Materials and Methods: Thirty cases with chordoma were treated by endoscopic transsphenoidal surgery between June 2000 and June 2006. Twenty-nine patients with chordoma were operated through a transnasal transsphenoidal approach between the nasal septum and middle nasal concha. First, the bony portion was removed with a high-speed drill in order to expose the chordoma. Then the tumor was resected in pieces using a rigid 30 degree and 70 degree endoscope. One case was performed using craniotomy to dissect parts of the tumor in the skull under the microneurosurgery, then to resect other parts of the tumor situated at the clivus, in the saddle area, and in the maxillary sinus, as well as at the infratemporal fossa under the orientation of neuroendoscopy. Eighteen cases were followed-up 10 to 18 months after operation.