Endoscopic pituitary surgery is a surgery performed through the nose and sphenoid sinus, aimed at removing pituitary tumors. The other name, transsphenoidal, means "through the sphenoid sinus". Endoscopic surgery can be performed with a microscope or endoscope, or both. The traditional microscopic technique involves the removal of a large portion of the nasal septum and a skin incision under the upper lip. Thus, the surgeon can see the sphenoid sinus area directly.
A minimally invasive method called endoscopic endonasal surgery creates a tiny incision at the back of the nasal cavity and minimizes the possibility of deterioration of the nasal tissues and overall anatomy. The ENT surgeon, on the other hand, works with a small camera connected to a light called an endoscope. Both methods aim to reach the pituitary. When the pituitary is reached as a result of these procedures, the neurosurgeon removes the tumor.
What Are the Symptoms of a Pituitary Gland Tumor?
Pituitary gland tumor may not show symptoms suddenly at first. For this reason, various disorders may arise as a result of complications that occur due to the time-consuming diagnosis process. We can explain these disturbances as follows:
- Headache: A tumor on the pituitary gland can cause a headache, and this pain is on the back of the patient's head compared to other types of headaches and can sometimes be severe in character. The pain caused by the tumor arising in the pituitary gland at the back of the brain can even affect the inner parts of the nose.
- Vision problems: In front of the pituitary gland is the anatomical location of optic nerves, and the tumor that grows on this gland causes visual disturbances by applying pressure to this area over time.
- Menstrual irregularities: The tumor, which causes the pituitary gland to secrete hormones excessively or inadequately, can also cause menstrual irregularities. The menstrual cycle returns to its original pattern after removal of the pituitary gland tumor.
- Sexual impotence: Pituitary gland tumor, which causes hormonal disbalances, causes sexual impotence in male patients.
- Sudden changes in mood: Since the tumor, which causes a mass effect and pressure on the pituitary gland, causes hormonal problems, the sick person exhibits a mood that can range from laughter to sudden anger.
- Infertility: Infertility cases that may occur due to a pituitary gland tumor can be improved after tumor removal. However, this can sometimes be permanent.
- Changes in lactation pattern: The pituitary gland plays an important role in the secretion of the hormone prolactin, so the tumor that may occur here can cause this hormone to be secreted excessively or inadequately, leading to changes in the amount of breast milk produced.
- Cushing's syndrome caused by excessive secretion of ACTH: Excessively secreted ACTH hormone causes fragile bone formation, excessive weight gain, skin spots and emotional changes and can trigger the syndrome called Cushing’s.
- Excessive growth or delay in growth: Excess growth hormone, which may occur due to a pathology of the pituitary gland, causes more growth than normal in pediatric patients, and if it is secreted less, it causes delayed growth.
- Tiredness and impatience: Problems and irregularity in hormones causes problems such as anger, fatigue, restlessness and impatience.
How is Pituitary Gland Tumor Diagnosed?
If a pituitary tumor is suspected as a result of the routine physical examination, a more detailed examination is performed with Magnetic Resonance Imaging (MRI). In addition, in order to determine the hormonal activities of the tumor, various hormone levels in the blood should be assessed and examinations related to possible vision problems should be carried out.
These assessments should be performed in a multidisciplinary manner by medical professionals. Since the symptoms of pituitary tumors are usually related to the function of hormones, the first evaluations are mostly made by endocrinology and internal medicine specialists. Visual assessments are made by ophthalmologists.
If it is decided that surgical treatment is required, the doctor who will be performing this operation is a neurosurgery specialist. The role of the otolaryngologist is to assist the neurosurgeon in some pituitary gland operations performed with a through the nose technique. The cooperation of these two surgical specialties is valid in endoscopic pituitary surgeries, which are being used more and more today.
How is Endoscopic Pituitary Surgery Performed?
For the operation, the endoscopic technique must first be determined and then the patient must be prepared for the operation. Before the operation, which is initiated by entering the nose, the patients nose and sinuses should be examined. If symptoms such as infection in the sinuses, problems in smelling, nasal discharge and headache are detected in the examination, first of all, treatment should be applied to solve these issues. However, before the endoscopic pituitary tumor surgery, required tests should be integrated together with the physical examination and neurological examination of the patients. The patient is informed in detail how the endoscopic pituitary tumor removal surgery proceeds.
Technological systems called navigation and endoscope are used in endoscopic pituitary surgery, which is an operation performed jointly by neurosurgeons and ENT specialists. As the first surgeon to start the operation, the ENT specialist starts from the sinus with the endoscope and reaches to the pituitary gland located at the skull base. After that, the neurosurgeon completely cleans the tumor and ends the operation. In some cases after the operation, it is not necessary to place a tampon in the nose. The tissue damaged in the operation can be corrected with different techniques. After the operation, the patient is discharged in a short period of time and can quickly recover and return to his normal life.
What are the Advantages of Endoscopic Pituitary Surgery?
The advantages of endoscopic pituitary surgery can be listed as follows:
- Possible septal, nasal, sinus and dental complications that may occur in endoscopic pituitary surgery are less likely to occur compared to the older methods employing microscopic techniques.
- Retractor or nasal speculum are used in microscopic operations. This causes the structures inside the nose to be damaged. In endoscopic pituitary surgery, the nasal cavity is used as a natural corridor to reach the sphenoid sinus, so that the tooth roots are not damaged and the septum separating the nostrils from each other is not damaged.
- In the endoscopic pituitary operation, the patient is not exposed to radiation, as there is no need to take X-rays during the procedure.
- Since the image provided in endoscopic pituitary surgery covers a wider visual field than the image presented by the microscope, the endoscope can be inserted into the cavity formed as the tumor is removed, allowing the surgeon to visualize the parts that may have been left behind after the tumor removal.
- Endoscopic pituitary operations provide a high success rate in people with Acromegaly or Cushing's disease.
- Thanks to endoscopic pituitary surgery, giant pituitary adenomas can be removed in just one session.
- Leakage of cerebrospinal fluid from the nose is one of the most undesirable consequences of pituitary surgeries. Thanks to the endoscopic pituitary surgery, the cerebrospinal fluid leaking from the nose is treated again through the nose during the operation, so that a second brain surgery is not required for the patient.
What are the Complications of Endoscopic Pituitary Surgery?
Every surgical operation has some risks. Every surgery has risks, but this rate may vary according to the experience and skill of the surgeon. Some risks can be fatal, while others can be corrected with treatment. The most important factor to know about the endoscopic pituitary tumor operation is that some complications that develop due to the pressure on the pituitary gland before the diagnosis and treatment, may not be 100% eliminated after the operation depending on the extent the pituitary gland is affected by mass effect before the surgery. For example, if the nerves are damaged as a result of excessive pressure on the optic nerves, permanent blindness may occur. During the operation, the pituitary gland may be damaged, and cerebrospinal fluid may flow out of possible holes that may occur in the skull lining. Meningitis can occur. Adhesion may occur in the tissues in the sinus and may cause congestion. There may be nosebleeds, although in very few of the patients, this bleeding can continue for a long time after the operation. Finally, the nose may also be deformed, but this can be corrected later with surgery.