Rhinologic outcomes of concurrent operation for pituitaryadenoma and chronic rhinosinusitis: An early experience

Kyung Wook Heo, M.D.,* and Seong Kook Park, M.D., Ph.D.*#

ABSTRACTBackground: The transsphenoidal approach (TSA) is the procedure of choice for the vast majority of pituitary neoplasms. Sinusitis is

considered a contraindication to TSA because of possible transcranial spread of infection. This study was performed to determine if TSA forpituitary tumors could be extended to patients with pituitary adenoma and chronic rhinosinusitis (CRS).

Methods: Medical records, including rhinologic outcomes, were retrospectively assessed in 11 consecutive patients who underwentconcurrent TSA and endoscopic sinus surgery (ESS) because of pituitary adenoma and CRS between May 2004 and October 2007.

Results: The 11 patients consisted of 5 men and 6 women, with a mean age of 55 years (range, 31–69 years) and average follow-up of24.4 months (range, 6–44 months). Preoperatively, all patients had symptoms of CRS, but none had acute exacerbation of rhinosinusitis. Allpatients had CRS and two had nasal polyps. TSA was via the transcolumellar transseptal approach in seven patients and the transnasalapproach in four patients. No postoperative complications due to ESS were observed. Two patients, including one with sphenoid aspergillosis,had preoperative unilateral sphenoid sinusitis, which was managed by ESS on the involved side, with TSA performed concurrently throughthe contralateral healthy sphenoid sinus. There was one case of postoperative sphenoid sinusitis and one case of septal perforation due to TSA.There were no postoperative intracranial complications, including meningitis and brain abscess.

Conclusion: Concurrent TSA and ESS can be performed in selected patients with CRS and pituitary adenoma. Future studies shouldinvolve more patients and longer follow-ups.

(Am J Rhinol 22, 533–536, 2008; doi: 10.2500/ajr.2008.22.3220)

Key words: Complications, endoscopy, intracranial, outcomes, pituitary neoplasms, sinusitis, surgery, transsphenoidal

Surgical access to pituitary tumors can be accomplishedusing several approaches, which have evolved with in-

novations in surgical techniques and advances in instrumen-tation.1 The transsphenoidal approach (TSA) remains the pro-cedure of choice for the vast majority of pituitary tumors2

because it is associated with lower morbidity and mortalityrates.3–5 In contrast, the transcranial approach is performedfor specific indications and is used for 1–4% of pituitarytumors that require surgical treatment.3,4

Paranasal sinus (PNS) surgery has also progressed, becauseof the development of new and innovative techniques inexposure and visualization. Endoscopic sinus surgery (ESS) isusually the best approach in patients with chronic rhinosinus-itis (CRS).6

Because of the possible transcranial spread of infection,rhinosinusitis has been considered a contraindication to TSAfor pituitary tumors. There has been various descriptionsindicating the transcranial approach for pituitary tumors withsinus infection, such as active sinus infection,2 active acute orchronic sinusitis,7 and sphenoid sinusitis.8,9 To our knowl-edge, however, there have been no reports showing thatrhinosinusitis contributed to the spread of infection after TSAfor pituitary tumors. We therefore retrospectively reviewed a

series of patients who underwent simultaneous TSA and ESSbecause of pituitary adenomas and CRS. We evaluated therhinologic outcomes of ESS to determine if TSA for pituitarytumors could be extended to these patients.

METHODSBetween May 2004 and October 2007, 147 patients under-

went TSA because of pituitary adenomas, with 11 (7.5%)undergoing concurrent TSA and ESS at our institution. Allpatients had pituitary adenomas. Neurosurgical indicationsfor TSA included visual field defect, acromegaly, and amen-orrhea refractory to maximal medical treatment. All patientsunderwent comprehensive endocrinologic and ophthalmo-logic evaluations before surgery. Neuroradiological evalua-tion included sellar magnetic resonance imaging (MRI) withand without i.v. contrast. Postoperative MRI, with or withoutPNS computed tomography (PNS CT) as needed, was sched-uled 3–6 months after surgery.

The diagnosis of CRS was based on the 1996 RhinosinusitisTask Force Report.10 Initially, 22 patients under considerationof TSA complained of symptoms, including nasal obstruction,facial congestion, discolored nasal discharge, and hyposmiafor �12 weeks. We excluded patients who complained ofacute onset of the aforementioned symptoms within 12 weeks.They were evaluated by nasal endoscopy and multiple aller-gen simultaneous test (MAST Immunosystems, MountainView, CA). Of these, 16 patients were confirmed as havingCRS because their nasal endoscopic findings showed mucoiddischarge from middle or superior meatus and diffuse muco-sal swelling of the nasal cavity, and 14 were treated with theantibiotics cefuroxime axetil or cefixime only for 2 weeksbecause neurosurgical conditions did not permit further delayof TSA. PNS CT was subsequently performed in nine patients

From the *Department of Otorhinolaryngology–Head and Neck Surgery, and #PaikInstitute for Clinical Research, Inje University, College of Medicine, Busan PaikHospital, Busan, KoreaSupported by the 2005 Inje University research grantThis study was approved by the Institutional Review Board of Busan Paik HospitalAddress correspondence and reprint requests to Kyung Wook Heo, M.D., Departmentof Otorhinolaryngology–Head and Neck Surgery, Inje University College of Medicine,Busan Paik Hospital, 633-165, Keakeum-dong, Busanjin-Ku, Busan, 614-735, KoreaE-mail address: heokw96@kornet.netCopyright © 2008, OceanSide Publications, Inc., U.S.A.

American Journal of Rhinology 533

having persistent symptoms after medication, and two ofthese patients underwent emergency surgery (concurrent TSAand ESS) because of visual defect. After antibiotic treatment,all patients showed various lesions on PNS CT scans, andtheir average Lund-Mackay score11 was 10.3 (range, 6–19;Table 1). They received concurrent TSA and ESS.

After orotracheal intubation, ESS was performed as de-scribed.12 Each opened sinus was irrigated with 200 mL ofsaline solution containing ceftriaxone 2.0 g. For patients whounderwent TSA through the transnasal endoscopic approach,the sphenoidal ostium was enlarged with a micro-Kerrisonpunch to a size sufficiently large to admit simultaneous pas-sage of the endoscopes and surgical instruments. The poste-rior third of the nasal septum was completely resected afteradequate elevation of the mucoperiosteum, followed by theremoval of the sphenoid rostrum. The anterior wall of thesphenoid sinus was removed using a micro-Kerrison punch.

For patients who underwent TSA through the transcolu-mellar endoscope–assisted transseptal approach, the latterwas begun by out-fracture of all turbinates. Complete trans-fixion and Padovan incisions were performed at the columellaand were extended using marginal incisions. After exposingthe caudal end of the septal cartilage, the bilateral mucoperi-chondrial flaps were elevated from the septum. The bonycartilaginous junction of the septum was separated, and thecartilaginous septum was displaced to one side of the nasalcavity. The remaining bony septum was harvested for recon-struction of the sellar floor. After exposure of the anterior wallof the sphenoid sinus, the same procedure was performed asthat used in the transnasal endoscopic approach. The pituitaryadenoma was removed or decompressed, and the sellar floorwas reconstructed using the harvested bone, as well as withabdominal fat in three patients. In patients who underwentthe transcolumellar endoscope–assisted transseptal approach,a silastic sheet was applied to both sides of the nasal septumfor 7 days. Nasal packing with water-absorbing sponges was

maintained for 2 days, and all patients were discharged 10–14days after surgery.

Operative notes and intraoperative videos were reviewed.Postoperative nasal endoscopic findings, clinical notes, andimaging reports were reviewed to document postoperativerhinologic outcomes. The study protocol was approved byour Institutional Review Board, and written informed consentwas obtained from all patients.

RESULTSPatients who underwent concurrent TSA and ESS at our

institution consisted of five men and six women, with a meanage of 55 years (range, 31–69 years), and with mean follow-upof 24.4 months (range, 6–44 months; Table 1). All 11 patientswere confirmed as having CRS, but none exhibited acuteexacerbation of rhinosinusitis. Two patients (cases 3 and 5)had nasal polyps at the middle meatus. TSA was through atranscolumellar endoscopy–assisted transseptal approach inseven patients and through a transnasal endoscopic approachin four patients, according to the preference of the neurosur-geon. During ESS, mucosal hypertrophies were found in all 11patients, and 6 patients showed purulent discharges frominvolved sinuses. In case 4, The sphenoid sinus pathology wasaspergillosis (Fig. 1).

All 11 patients showed improvement of CRS both by symp-tom and nasal endoscopy. Intraoperative sinus findings werenot significant for ESS outcomes. The rhinologic complica-tions of patients are summarized in Table 1. One patient (case3), who did not show preoperative involvement of the sphe-noid sinus, experienced postoperative sphenoid sinusitis andwas managed by 2 weeks of conservative treatment, includingsystemic antibiotics, topical steroid spray, and warm salineirrigation. In two patients (cases 4 and 8), preoperative MRIand PNS CT showed CRS at the unilateral ethmoid and sphe-noid sinus, along with a pituitary adenoma. ESS was per-

Table 1 Demographic characteristics, preoperative Lund-Mackay scores, involved sites, operative findings ofsinuses, and postoperative complications in 11 patients undergoing concurrent surgery for pituitary adenomaand chronic rhinosinusitis

Case Sex/Age(yr)

PreoperativeLund-Mackay

Score

Involved Site Operative Findingsof Sinuses

Complication Follow-Up(mo)

1 Male/69 12 O, E (B) MH, PD None 442 Male/34 11 O, E (B) MH None 403 Female/31 6 O, E (U) MH Sphenoid sinusitis 384 Female/67 6 E, S (U) MH, fungalball None 325 Male/51 19 O, E, M, F (B) MH, PD None 316 Male/37 11 O, E (B) MH, PD None 267 Female/50 13 O, E, M (B) MH, PD None 198 Female/73 8 O, E, S (U) MH None 159 Male/68 6 E, M (U) MH Septal perforation 9

10 Female/55 15 O, E, M (B) MH, PD None 811 Female/65 12 O, E (U) MH, PD None 6

B � bilateral; E � ethmoid sinus; F � frontal sinus; M � maxillary sinus; O � ostiomeatal complex; S � sphenoid sinus;U � unilateral; MH � mucosal hypertrophy; PD � purulent discharge.

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formed at the involved sinuses, and TSA was performedsimultaneously through the contralateral healthy sphenoidsinus. One patient (case 9) had a 0.5-cm-diameter perforationat the posteroinferior septum because of TSA, but withoutsymptoms. There were no postoperative intracranial compli-cations, such as meningitis or brain abscess. All patients havebeen followed regularly as outpatients.

DISCUSSIONThe evolution of pituitary surgery during the past 10 years

has been characterized by a progressive trend toward lessinvasive surgical approaches to the gland.13 The transcranialmethod was replaced by the transseptal technique when equalsurgical results were achieved without the need to remove theskull or retract the brain.13 The traditional transseptal TSA,however, is associated with postoperative sequelae includingfacial and endonasal swelling and pain.14 In traditional sub-labial transseptal TSA, postoperative morbidity may be com-pounded by the frequent need for nasal packing or septal

splints. Sinonasal complications are common, including rhi-nosinusitis, nasal synechiae, septal perforation, and numbnessof the upper incisors.14 To reduce patient morbidity, mostpatients undergo surgery through endoscopic TSAs, via tran-snasal or transseptal routes.1,13–15 Endoscopes with angledlenses provide direct visualization of the surgical field, withsuperior exposure when compared with microscopes.16,17 Inaddition, fully endoscopic TSA results in acceptable remissionrates.18

Among the indications for a transcranial approach to pitu-itary adenomas are dumbbell-shaped adenomas with severeconstriction at the diaphragma sellae, parasellar extension,inaccessible suprasellar extension, fibrous pituitary adenomaswith large suprasellar extension, active sinus infection, coex-istence of pituitary adenomas and adjacent aneurysm, andectatic intrasellar kissing carotid arteries.2 A transcranial ap-proach to sellar region tumors is also indicated for patientswith sphenoid sinusitis.8 Little is known, however, about theimpact of preoperative CRS on TSA.

Figure 1. Preoperative T2-weighted magnetic resonance images (MRIs) in patient 4, showing a pituitary tumor (black arrows) and a rightsphenoid sinus lesion (white arrows) on (A and B) axial and paranasal sinus sagittal (C) computed tomography (PNS CT). (D) Fungalmaterials (white arrow) can be seen in the lower part of the right sphenoid sinus in the operative field. (E) Postoperative T2-weighted MRIand (F) PNS CT showing resolution of right sphenoid aspergillosis and improvement of the pituitary adenoma.

American Journal of Rhinology 535

We initiated concurrent TSA and ESS because of the religionof one patient (case 1). This patient, a Buddhist priest, had apituitary adenoma requiring surgery, and a transcranial ap-proach was planned due to CRS. He refused this approachbecause Buddhists strictly abstain from injuring the head. Theauthors, the patient, and neurosurgeon then comprehensivelydiscussed concurrent TSA and ESS. After being informed aboutthe impact of CRS and possible complications, we performedconcurrent TSA and ESS without any complications due to ESS.

The remaining patients in our series, who had pituitaryadenomas and various types of CRS, also underwent simul-taneous TSA and ESS without any complications due to ESS.Two patients had preoperative unilateral sphenoid sinus le-sions and pituitary adenomas, which were successfully man-aged by concurrent ESS and TSA through the contralateralhealthy sphenoid sinus. In addition, one patient was diag-nosed with pituitary adenoma and sphenoid aspergillosis, butnone had preoperative bilateral sphenoid sinus lesions. Wesuggest that in patients with preoperative CRS in bilateralsphenoid sinuses, transcranial removal of the pituitary ade-noma or a staged operation, consisting of ESS followed byTSA, could be performed.

Transseptal TSA has been found to result in various nasalcomplications, including epistaxis, septal perforation, sinus-itis, and nasal dryness.19–21 Rare complications include saddlenose deformity and mucocele formation.20,22 Postoperativesinusitis is the most common complication, with an incidenceof 15%.20 Of our 11 patients, 2 had complications caused byTSA, 1 each with septal perforation and sphenoid sinusitis,but these complications were not caused by ESS. We foundthat the incidence of postoperative sinusitis was very low (1 of11), which may be caused by the method of sellar floor recon-struction. We performed sellar floor reconstruction using ab-dominal fat only in three early patients. Abdominal fat in thesphenoid sinus from the sellar floor may disturb mucociliaryclearance and obstruct the ostium of the sphenoid sinus.

CONCLUSIONConcurrent TSA and ESS can be performed in selected

patients with CRS and pituitary adenoma. Future studiesshould involve more patients and longer follow-ups.

ACKNOWLEDGMENTSThe authors thank Sun Il Lee, M.D., and Young Gyun Jeong, M.D.,

for involving us in the management of their patients.

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