Mayo Clinic otolaryngologists Garret W. Choby, M.D., and Jamie J. Van Gompel, M.D., demonstrate an endoscopic transsphenoidal pituitary approach for a patient with a nonfunctioning macroadenoma.
Garret W. Choby, M.D.
Jamie J. Van Gompel, M.D.
This is Garret Choy. And today, we'll be illustrating a case of an endoscopic transformative approach to a pituitary uh tumor. This is a case with myself and Doctor Van Gumpel. What you can appreciate on this MRI scan is that there's quite a sizable tumor. This is a nonfunctioning pituitary macroadenoma with compression of the optic chiasm. In fact, this patient's main presenting symptom was bi temporal heia. The other thing that you can appreciate about this MRI scan is that this patient has relatively limited sphenoid pneumatization with a very limited lateral recess on the right side and a slightly larger lateral recess on the left side. Initially, it's important to out fracture the inferior middle and superior ters. As you'll see here, typically, for most pituitary cases, there's relatively normal nasal anatomy and therefore, it's fairly easy to identify the sphenoid o just medial to the super terminate. Here we are the freer elevator, uh out fraction at middle, terminate in identifying the superior terminate. Ideally, you can advance this for your elevator just between the middle and superior turbinates to get a nice out fracture. Uh of that middle turbinate. This patient's turbinates were especially ote So it took a fair bit of force to get those to uh move over for us. Now, here we are out fractioning the super terminate in identifying the natural os theno sin is just medial to this. Uh and again, pretty normal anatomy. In this case, is the patient has no uh additional sin, nasal issues. And there's that uh natural ati pheno sinus. There. Here we are using a one millimeter upgoing kerosene as well as a speed punch to open the oss on this side, we are planning to raise a nasal septal flap in this case. And by releasing this mucosa around the oss that will allow that flap to be lifted away nicely and then tucked into the nasopharynx. Uh after it has been raised, we're careful here not to go inferiorly below the oss and thus compromise the pedicle. So we're staying a media lateral and just superior. Here, we are coming into the patient's contra or nasal cavity and again, out fracturing the inferior middle and superior terminates as you can see here. Uh And now allows us to identify the natural O P on this side as well. So here's the patient's uh left and then again, we'll open that uh with a one kero in here and uh allow that mucosa to be released here. We are back in the right nasal cavity ready for the next step, which is creating a poster septectomy. I do that behind the head of the middle terminate and just the level of the natural oss that ensures that as you take this poster, you're not compromising the arterial source for your nasal septal flap. I keep a pledge on the contralateral side to protect the contralateral middle turbinate from the freer and the through cut. As you can see here, as we're taking that septum directly back to the natural loss on both sides, which will allow us to peel down the mucosa over the of the rostrum. In this case, I elected to raise a right sided nasal seppo flap as it was a sizable tumor and you were anticipating a likely CS F leak. So here we are outlining the incisions for that. The important part is getting in the proper plane early on and then raising this from interior to posterior. Uh Usually we'll leave some of the tenacious fibers up high uh to have keep this elevated while we raise it down low. And then usually we'll come across those with a scissor uh towards the end to release them and then tuck this into the nasopharynx. As you can see this exposes the entirety of the bone of the rostrum. You can see the cue of the rostrum being exposed there as well. Take a nice uh downgoing two millimeter kerosene and remove the bone uh of the rostrum here down to the cliver recess and the floor, the sinus in order to uh remove the cure of the rostrum. Then here we are on the patient's contralateral side, uh we always uh preserve a rescue peta as well as you can see. In this case, we're gonna peel that mucosa down towards a coen and peel it over laterally, exposing that bone again, to allow us to use a downgoing two millimeter kerosene to take this down to the floor, the sinus as well. And once that's released superiorly, uh you can use a closed Jan in Middleton or a Ferris uh Smith uh forceps in order to remove that cue to rostro when removing this piece of bone from the nasal cavity. It's important that you do not uh accidentally shear the mucosa on the way out. So it's important to visualize this and remove it in a fashion that's a traumatic uh to the surrounding nasal cavity. Then you can begin to remove the inner sin ations as you can see here. Uh the cell has been quite dilated from the tumor itself, but the partitions can be removed back as far as possible. Now, I think it's important to have uh the sphenoid exposed from thelial recess at the floor of the sinus ideally to hold up to the plat in most cases to allow adequate visualization for your neurosurgical partners. Here we are with an upgoing two millimeter carrison and a 45 degree through cut, expanding that uh super lateral portion of the stood as you can see here at this juncture. Uh our neurosurgical partners will enter the field and de mucosal uh the area overlying the cella. Again, as you can see in this case, it's quite an expanded cella due to the patient's large tumor and remove the hospital's inner sinus cations. Now, after the tumor has been removed, what you can see here is uh a bit of gel foam deep and then my neurosurgical partner is placing in some abdominal fat uh there as well. There was not a significant CS F link during in this case. So we did not feel the need to place the septal flap over the defect. Instead, what we elected to do was to replace the nasal septal flap overlying the septum uh where it came from. The important things here are to make sure that the septal flap is in the proper orientation and unfurled completely. As you can see in this particular case, then ordinarily, I'll use a four oh uh plane gut sutra on a keith needle to suture this into place in a quoting fashion. In order to hold that into place in certain situations, you may elect to use stys sheeting or dole splints to further provide some support for that uh septal flap. And then here we are examining the flap post yearly after it's been suited into place, ensuring that it's uh lying back nicely on the spot that we raised it from. In summary, key aspects for a pituitary approach are opening the natural os, the sphenoid on both sides and then gaining full access to the bilateral sphenoid sinus by removing the keel of the rostrum and having access from the cliver recess up towards the planum depending on the extent of the tumor resection. It's also key to realize that this is team surgery and the person running, the nasal endoscope has a key portion of the surgery assisting his or her neurosurgical partner with visualization and acting as an extra set of eyes.
