Removal of pituitary tumors is a team effort:
1) The anesthesiologist puts the patient to sleep, monitors vital signs and fluid intake & output.
2) The otolaryngologist opens the way to the sella.
3) The neurosurgeon removes the tumor.
4) The pathologist performs a frozen section to confirm the diagnosis.
5) The otolaryngologist closes the wound.
6) The anesthesiologist wakes the patient.
The pituitary gland (hypophysis) is located in the base of the skull behind the eyes. It is surrounded by a spherical bone called sella turcica or Turkish saddle. The optic nerves cross just above the sella and the sphenoid sinus is located just below. Reaching the sella from above requires opening the skull, retracting the brain and endangering the optic nerves. A much simpler way, is to approach the sella from the sphenoid sinus and the nose.
The sublabial trans-sphenoid approach to the sella turcica is an operation designed to expose the pituitary gland from below. A small (1 to 1.5 in) incision is made in the grove between the gum and the upper lip. Through this incision, the wall between the two nasal cavities (septum) is dissected and moved to the side. The sphenoid sinus is opened and the sella turcica is exposed.
At this stage, the neurosurgeon takes over, removes the tumor and closes the floor of the sella.
After the tumor is removed, the nasal septum is returned to its midline position. The incision is closed with absorbable sutures that do not need removal. The nose is packed for two to three days.
As in all nasal and sinus operations, the undesirable results that may occur include a hole in the septum, postoperative bleeding (usually easy to control), nasal crusting, and very rarely, a change in appearance. Because of the proximity of the dissection to the incisors, these teeth and a small area of the hard palate behind them, may feel numb for 2 to 3 months. An extremely rare event is an occasional discoloration of an incisor.
FOR PATIENTS WITH DENTURES:
In patients who have an upper denture, the incision is made in the gum. It is imperative that the patient brings the denture to the operating room. The denture is placed on the gum at the end of surgery to prevent the gum from swelling. If this is not done immediately after surgery, new dentures would have to be made because of gum swelling. Patients who have upper and lower dentures, should bring them both to the operating room.
Other problems are related to the removal of the tumor. The most common are cerebrospinal fluid (CSF) leak, diabetes insipidus, and other hormone-related problems. These complications are better discussed with the neurosurgeon.
Finally, in selected cases, a piece of abdominal fat or a piece of fascia lata from the leg are used for closing the sella. Like any other wound in the body, these are prone to the same undesirable results, from wound infection, to keloid formation and possibly, infection.
I have discussed the risks, benefits and alternatives of the procedure/treatment to the patient/patient representative. I answered the patient’s/patient’s representative’s questions regarding the procedure/treatment.
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