Pituitary Adenoma Surgery
What Is The Pituitary Gland?
Although it is very small, about the size of a pea, the pituitary gland controls many of the functions of the body by producing hormones. It is located in the sella turcica “Turkish saddle” which is a bony cavity inside the skull below the brain. The pituitary gland is divided into an anterior and posterior lobe. The Brain controls the pituitary gland by sending messengers in the blood to the anterior pituitary and through nerve connections to the posterior pituitary. The anterior pituitary gland controls the body’s steroid production, organ growth, bone and muscle growth, the organs of reproduction, the thyroid and the mammary glands, darkening skin, inhibiting pain and assisting the immune system. The posterior pituitary gland regulates water balance in the body through the kidneys as well as stimulating lactation and contractions during pregnancy.
What Happens If The Pituitary Gland Malfunctions?
If any portion of the pituitary gland starts to grow then the gland may expand which is termed a pituitary adenoma. The sella turcica has very little room to expand and the expansion may decrease, increase or have no effect on the functions of the gland. There can be an increasing some of the hormones and decrease of others. Making too much hormone can cause gigantism, lactation in both men and women or erectile dysfunction. Making too little hormone can affect water balance or can affect multiple hormones. Another disorder is when cerebrospinal fluid leaks into the sella turcica and pressurizes the pituitary gland. This generally causes no symptoms but can cause the sella turcica to look “empty on CAT scan or MRI and is called “empty sella syndrome”. This can also cause the pituitary gland to make too much or too little hormone.
How Is Pituitary Dysfunction Diagnosed?
A patient with a noncancerous pituitary tumor, or pituitary adenoma, may have headaches or vision changes. As the pituitary adenoma grows it will apply pressure to surrounding structures and is especially associated with loss of peripheral vision. Oversecretion of a hormone will give you symptoms of what that hormone does. For example, a growth hormone tumor can cause coarsened facial features, enlarged hands, and feet, high blood sugar, heart problems, and other signs. An undersecreting pituitary can cause nausea and vomiting, feeling cold, sexual dysfunction, weakness, or weight gain or loss. Your doctor can perform blood and urine tests to check for levels of these hormones or may check for the levels of the products created by these hormones. Imaging tests such as an MRI (Magnetic Resonance Image) or computerized tomography of the brain will show the size and shape of the pituitary gland and surrounding area in detail. A vision test will show if the tumor is pressing on your optic nerves which can result in permanent vision loss. You may be referred to an endocrinologist for additional testing. The diagnosis of a pituitary tumor doesn’t mean that you have cancer. Almost all pituitary tumors are “benign” meaning that they are non-cancerous and will not spread. However, they need to be diagnosed and treated as early as possible to prevent complications and disruption of your quality of life.
Before Transphenoidal Surgery
Prior to surgery, you will have a CT scan, MRI, or both to evaluate the size and shape of the gland and tumor. Lab testing will also be done before your surgery to see if the tumor is causing hormonal imbalances. These tests will establish a baseline for comparison after the surgery is completed, and determine if the surgery has shown improvement.
What Technique Is Used To Remove A Pituitary Adenoma (Transphenoidal Adenomectomy)?
Generally, the pituitary adenoma is approached through the nose. Incisions are made inside of the nose at the front of the nasal septum and a tunnel is made along the cartilage and bone of the septum to the sphenoid sinus. The surgery is called a “transsphenoidal approach”. This is generally performed by an otolaryngologist as they have the highest level of surgical training inside the nose and sinuses. The front wall of the sphenoid sinus is removed providing access to the sella turcica. The wall of the sella turcica is removed to expose the pituitary adenoma. At this point in the surgery, the Neurosurgeon will take over and take out the tumor (transphenoidal adenomectomy). The outside layer of the adenoma is incised and the soft tumor is either suctioned or curetted from the sella turcica and brain. Clear cerebrospinal fluid (CSF) leaking into the sphenoid sinus at this point is a normal part of the procedure. The Otolaryngologist will then close the area of tumor removal and connection to the brain with muscle, fat or mucosal flaps and sealants. This is to prevent leakage of CSF into the nose. The septoplasty is completed to restore the septum to its midline position to restore nasal function.
Pituitary Surgery Aftercare
You will spend a day or two in surgical care for close monitoring after surgery. Most patients are able to return home 3-5 days after surgery with strict instructions not to blow their nose and instructions on how to care for the incision on their abdomen. Blood tests will be conducted to determine if the surgery was successful and see if there are still underlying hormone imbalances, we will also monitor urine outtake and nose drippage to see if the surgery was conducted properly. Two weeks after surgery you will be able to return to most normal activities. For at least a month after surgery weight lifting, strenuous exercise, bending, and lifting must be avoided. It is normal to experience fatigue, nasal congestion, and sinus type headaches. Yours follow up visits with Dr. Mourad you can expect to have blood tests done to continue to follow your progress and to determine what medication you may need.
What Are The Complications Of Pituitary Tumor Surgery?
Although pituitary surgery is relatively safe, it is still surgery on your brain and there can be complications. There can be neurological deficits, bleeding, hypopituitarism (low hormone production) from the surgery, sinusitis, nasal obstruction, CSF leaks, hydrocephalus, meningitis, and death. You may need to be on medications for the remainder of your life to replace those lost with tumor removal, this is called pituitary hormone replacement therapy.
How Can Dr. Moustafa Mourad Help?
Dr. Mourad is a double board certified Otolaryngologist and Facial Plastic Surgeon with extensive experience in approaching the pituitary and controlling CSF leaks. He can perform small repairs of CSF leaks up to and including large leaks needing local or even free flap tissue from another area of the body. He will work with a board-certified Neurosurgeon at Lenox Hill Hospital as well as facilitating treatment with an Endocrinologist. If you feel we can help you please give us a call.
Select Relevant Publications
Kadakia S, Chan D, Ducic Y, Cristobal R, and Mourad MW. Increased local recurrence in advanced parotid malignancy treated with mastoidectomy without lateral temporal bone resection. Oral and Maxillofacial Surgery. 30 Sep 2016, 21(1):7-11. Link to Article.