Otolaryngologist/Pituitary Adenoma

[postbacpremed87]

I know I am a pre-med student and I don't deserve to be on the "hallowed halls" of the resident pages yet, but I had a question...something I am curious about.

Would an Otolaryngologist with a fellowship in head/neck oncology be the type of physician who dealt with a pituitary adenoma?

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[resxn]

I know I am a pre-med student and I don't deserve to be on the "hallowed halls" of the resident pages yet, but I had a question...something I am curious about.

Would an Otolaryngologist with a fellowship in head/neck oncology be the type of physician who dealt with a pituitary adenoma?

It is becoming increasingly more frequent but the pituitary adenoma remains largely the realm of the neurosurgeon in most places across the country. ENT's used to frequently do the transseptal approaches for the neurosurgeon, but as the neurosurgeons have become more practiced on intranasal anatomy, fewer and fewer ENT's do the approaches anymore.

 

[postbacpremed87]

Hey. Thanks a lot for the information. What would you say are the top 5 (most frequent) procedures done by an ENT who doesn't pursue a fellowship?

It is becoming increasingly more frequent but the pituitary adenoma remains largely the realm of the neurosurgeon in most places across the country. ENT's used to frequently do the transseptal approaches for the neurosurgeon, but as the neurosurgeons have become more practiced on intranasal anatomy, fewer and fewer ENT's do the approaches anymore.

 

[neutropeniaboy]

Hey. Thanks a lot for the information. What would you say are the top 5 (most frequent) procedures done by an ENT who doesn't pursue a fellowship?

Every academic center where I have been has two surgeons doing pituitaries. Of the 14 neurosurgeons I've ever worked with, only 2 have done pituitaries by themselves. And, boy, do they rip up the septum and turbs.

I would say that the top five procedures done by non-fellowship trained ENTs would be sinus surgery, tonsils, tubes, septoplasties, and superficial excisions. But, that's a guess. Of course, that's not necessarily the "right" question. The top five procedures done by one of my colleagues, who isn't fellowship trained, are CPA tumor resection, parotidectomies, parapharyngeal space tumors, cochlear implants, and pituitaries.

 

[lildave2586]

At my school, our fellowship trained rhinologist does trans-sphenoidal approaches for nearly all the pituitary adenomas in town. He frequently goes off campus to the privates to help out neurosurgeons in the community who request his services. I've seen him do one, pretty cool stuff.

 

[Leforte]

You do not need to be fellowship trained to do transsphenoidal approaches for pituitaries. The operation is well within the scope of the generalist. Aside from ensuring to preserve mucosal flaps, removing the posterior boney nasal septum/anterior sphenoid walls and removing sphenoid mucosa, there is nothing, in my opinion, that is really technically challenging. Nearly all of our faculty, aside from the facial plastic surgeons and laryngologist, are involved with these at some point throughout the year (whoever is available when NS needs the approach).

 

[Fah-Q]

You do not need to be fellowship trained to do transsphenoidal approaches for pituitaries. The operation is well within the scope of the generalist. Aside from ensuring to preserve mucosal flaps, removing the posterior boney nasal septum/anterior sphenoid walls and removing sphenoid mucosa, there is nothing, in my opinion, that is really technically challenging. Nearly all of our faculty, aside from the facial plastic surgeons and laryngologist, are involved with these at some point throughout the year (whoever is available when NS needs the approach).

Leforte -
Can you recommend a textbook chapter or an article that describes the trans-septal approach? I'm supposed to help a neurosurgeon next week and I've never done or seen one before. I do a lot of nasal surgery but we never did these approaches in residency. Thanks.

Fah-Q

 

[bobby6]

I think most people are doing a primarily transnasal approach by doing a posterior septectomy, drilling down the sphenoid rostrum and then thinning down the posterior bony sphenoid wall so the neurosurgeon can get into the pituitary with a kerrison punch.

I'm a general ENT and I agree its within the realm of general ENT. How I do it is using a suction cautery to cauterize the posterior 1-2cm of the septum at the attachment point to the sphenoid rostrum. Fracture the septum off the sphenoid and use a backbiter to remove the posterior septum. A saber or medtronic spinal drill works great to drill down the rostrum and sphenoid partition to the back wall of the sphenoid. A drill can be used to thin the posterior wall and a kerrison can be used to unroof the bone from the pituitary at which point the Neurosurgeon should have adequate exposure. Most are not packing the sphenoid cavity after unless there is an active CSF leak which you can then pack the cavity with abdominal fat.

Leforte -
Can you recommend a textbook chapter or an article that describes the trans-septal approach? I'm supposed to help a neurosurgeon next week and I've never done or seen one before. I do a lot of nasal surgery but we never did these approaches in residency. Thanks.

Fah-Q

 

[Leforte]

Feh-Q - PM me and I will send you a PDF that goes over the technique. Don't want to post it here since our library's online journal access has our personal info electronically printed in the margins of the PDF.

Briefly, here is the way I was taught to do them.

1. Inject nasal septum with 1% lidocaine/epi like you are doing a septoplasty and insert afrin soaked pledgets prior to NS putting the patient in the Mayfield (if they are doing image guidance - if they are not using guidance, prior NS prepping the pt).
2. Once pt is prepped, endoscopically approach the right sphenoid
3. Identify the right posterior septal bone/cartilage junctio
4. Using a Cottle elevator, endoscopically transect the septal mucosa at this junction from the skull base to the inferior most level of the right sphenoid
5. Elevate the mucosal flap posteriorly and then laterally over the right sphenoid face. You will need to use endoscopic scissors to divide the mucosa over the right sphenoid face both inferiorly and superiorly - the goal is create a laterally base mucosa flap than can be laid back down at the conclusion of the case.
6. You may need to perform a right total ethoidectomy to improve visualization and occasionally resect the right middle turbinate if it is a narrow nose - We try to avoid the turbinate resection since this tissue can be useful if a CSF leak develops postoperatively (which is rare).
7. Once this is done, endoscopically separate the cartilaginous septum from the posterior boney septum.
8. Using a Freer elevator, elevate the mucosa over the left sphenoid face. You do not need to make an incisions to do this.
9. At this point, insert the self retaining nasal speculum - the two blades should straddle the boney nasal septum with your first right mucosal flap under the right blade and the left mucosa flap/septal cartilage under the left blade.
10. Endoscopically enter both sphenoids as you normally would - widely open both sphenoidotomies with the Kerrison.
11. Using a large Kerrison, remove the posterior boney septum between the two sphenoidotomies - you may need to use the endoscopic drill to assist with this (although this is rare if you have big enough Kerrisons).
12. Once this is widely opened, you should be able to see both carotid arteries and the sella.
13. Remove the inter-sphenoid boney septations. You can use the neurosurgical pituitary forceps for this.
14. Strip the mucosa in both sphenoids.
15. Advance in the operative microscope and ensure that you have good visualization of sella and can see both carotids, the inferior most aspect of the sella and the skull base
16. NS will at this point open the posterior sphenoid an do what they do.
17. Once neurosurgery and completed their portion of the case and achieved hemostasis, using the microscopic, place a small piece of Duragen into the empty sells space (You can do this with NS if you want).
18. At this point, I fill the entire sphenoid common cavity with alternating thin layers of Tisseal and abdominal fat up to the level of the anterior sphenoid faces.
19. Remove the self retaining nasal speculum
20. Reflect the left mucosal flap and septum back into in anatomical position
21. Reflect the right mucosal flap back into its normal position.
22. Place 1/2 of Nasopore posteriorly to hold the mucosal flaps in place.
23. Place another Nasopore in the right nasal passage to help hold the other inplace and provide hemostasis
24. Wake up the patient.
25. Neurosugery manages the patient postoperatively, I check them daily when they are in the hospital to ensure no CSF leak or epistaxis.
26. Start saline irrigations in a week.
27. F/U in 1 month

This is the way I was taught and currently teach our residents. I do notice that bobby6 does not fill the sphenoid unless there is an issue - either way is fine really. Never had a leak postoperatively yet (knock on wood).

 

[bobby6]

Alot of the newer trained Neurosurgeons are doing the pituitaries endoscopically versus using a microscope. A microscopic technique requires larger exposure with need to do possible total ethmoidectomies to allow for the self retaining nasal speculum to fit.

I haven't had to do any ethmoidectomies or mucosal flaps as our neurosurgeon does the removal endoscopically with me holding the endoscope while he operates with two hands. The posterior septectomy allows enough room to fit the endoscope and instruments.

Feh-Q - PM me and I will send you a PDF that goes over the technique. Don't want to post it here since our library's online journal access has our personal info electronically printed in the margins of the PDF.

Briefly, here is the way I was taught to do them.

1. Inject nasal septum with 1% lidocaine/epi like you are doing a septoplasty and insert afrin soaked pledgets prior to NS putting the patient in the Mayfield (if they are doing image guidance - if they are not using guidance, prior NS prepping the pt).
2. Once pt is prepped, endoscopically approach the right sphenoid
3. Identify the right posterior septal bone/cartilage junctio
4. Using a Cottle elevator, endoscopically transect the septal mucosa at this junction from the skull base to the inferior most level of the right sphenoid
5. Elevate the mucosal flap posteriorly and then laterally over the right sphenoid face. You will need to use endoscopic scissors to divide the mucosa over the right sphenoid face both inferiorly and superiorly - the goal is create a laterally base mucosa flap than can be laid back down at the conclusion of the case.
6. You may need to perform a right total ethoidectomy to improve visualization and occasionally resect the right middle turbinate if it is a narrow nose - We try to avoid the turbinate resection since this tissue can be useful if a CSF leak develops postoperatively (which is rare).
7. Once this is done, endoscopically separate the cartilaginous septum from the posterior boney septum.
8. Using a Freer elevator, elevate the mucosa over the left sphenoid face. You do not need to make an incisions to do this.
9. At this point, insert the self retaining nasal speculum - the two blades should straddle the boney nasal septum with your first right mucosal flap under the right blade and the left mucosa flap/septal cartilage under the left blade.
10. Endoscopically enter both sphenoids as you normally would - widely open both sphenoidotomies with the Kerrison.
11. Using a large Kerrison, remove the posterior boney septum between the two sphenoidotomies - you may need to use the endoscopic drill to assist with this (although this is rare if you have big enough Kerrisons).
12. Once this is widely opened, you should be able to see both carotid arteries and the sella.
13. Remove the inter-sphenoid boney septations. You can use the neurosurgical pituitary forceps for this.
14. Strip the mucosa in both sphenoids.
15. Advance in the operative microscope and ensure that you have good visualization of sella and can see both carotids, the inferior most aspect of the sella and the skull base
16. NS will at this point open the posterior sphenoid an do what they do.
17. Once neurosurgery and completed their portion of the case and achieved hemostasis, using the microscopic, place a small piece of Duragen into the empty sells space (You can do this with NS if you want).
18. At this point, I fill the entire sphenoid common cavity with alternating thin layers of Tisseal and abdominal fat up to the level of the anterior sphenoid faces.
19. Remove the self retaining nasal speculum
20. Reflect the left mucosal flap and septum back into in anatomical position
21. Reflect the right mucosal flap back into its normal position.
22. Place 1/2 of Nasopore posteriorly to hold the mucosal flaps in place.
23. Place another Nasopore in the right nasal passage to help hold the other inplace and provide hemostasis
24. Wake up the patient.
25. Neurosugery manages the patient postoperatively, I check them daily when they are in the hospital to ensure no CSF leak or epistaxis.
26. Start saline irrigations in a week.
27. F/U in 1 month

This is the way I was taught and currently teach our residents. I do notice that bobby6 does not fill the sphenoid unless there is an issue - either way is fine really. Never had a leak postoperatively yet (knock on wood).

 

[Leforte]

Agree that the endoscopic resection by NS is probably going to be the way this operation is headed. Ours are not too keen on it yet since they loose depth perception. You can also use a clamp to hold the endoscopy and eliminate the need for you to hold the endoscope while the neurosurgeon uses both hands for the pituitary work.

If using the microscope for their portion, visualization can be difficult on the right lateral aspect which can necessitate the right ethmoidectomy, but have not seen the need for a left ethmoidectomy yet.

I hear you on the mucosal flaps, they can be a real PITA to preserve but I guess I am superstitious in that knowing my luck, the first case I try to do it without will be the one that leaks.