Pituitary adenoma is a benign intracranial adenoma and is the most common tumor in the saddle area, with an incidence of about 1 per 100,000. Clinical manifestations The pituitary gland is an important endocrine organ, containing several kinds of endocrine cells that secrete various endocrine elements. The endocrine manifestations of different types of pituitary adenomas are described as follows: (1) Growth hormone cell adenoma: In the early stage, the tumor is only a few millimeters in size and the main manifestation is excessive secretion of growth hormone. It can grow too fast and even develop into a giant in immature patients. In adulthood, the tumor may show signs of hypertrophy of the extremities. For example, the face changes, forehead is wide, jaw protrudes, nose is large, lips are thick, fingers become thicker, shoes and hats feel tight, several times to replace the larger models, and even must be specially made, some patients also have more meals, hair and skin roughness, pigmentation, numbness of fingers, etc.. In severe cases, they feel general weakness, headache and joint pain, hypogonadism, amenorrhea and infertility, and even complications of diabetes. (2) Prolactin cell adenoma: The main manifestations are amenorrhea, overflow of milk, infertility, axillary hair loss, pale and delicate skin, increased subcutaneous fat, as well as weakness, fatigue, drowsiness, headache, and hypogonadism. In men, the symptoms include loss of libido, impotence, breast enlargement, beard thinning, atrophy of the reproductive organs, reduction of sperm count, and infertility, etc. There are not many male and female patients. (3) Adrenocorticotropic adenoma: Clinical manifestations include centripetal obesity, full-moon face, buffalo back, polycythemia, purple lines on the skin of the abdomen and thighs, and increased fine hair. In severe cases, amenorrhea, loss of libido, general weakness, or even bedridden. Some patients also have hypertension, diabetes, etc. (4) Thyroid-stimulating hormone tumor: Rarely, hyperthyroidism is caused by the overproduction of thyroid-stimulating hormone in the pituitary gland, and the symptoms disappear after the tumor is removed. The symptoms of hyperthyroidism disappear after removal of the pituitary tumor. There are also cases of focal hyperplasia of the pituitary gland due to hypothyroidism feedback, which gradually develops into pituitary adenoma. (5) Follicle-stimulating hormone cell adenoma: Very rare, only a few reports of clinical hypogonadism, amenorrhea, infertility, reduced sperm count, etc. (6) Melanin-stimulating hormone cell adenoma: Very rare, only a few patients reported black skin pigmentation without cortisol increase. (7) Endocrine inactive adenoma: In the early stage, the patient has no special feeling that the tumor is growing and can compress the pituitary gland causing clinical manifestations of pituitary insufficiency. (8) Malignant pituitary tumor: short history and rapid progress of disease, not only the tumor grows to compress the pituitary tissue, but also invades to the surrounding area, causing destruction of the bone of the saddle base or infiltrating into the cavernous sinus, resulting in actinic nerve paralysis or abducens nerve paralysis. Sometimes the tumor penetrates the saddle base and grows into the pterygoid sinus, and the neurological symptoms are not obvious for a short period of time. 2.Visual field disorder Early pituitary adenoma often has no visual field disorder. If the tumor grows up and extends upward to compress the visual cross, visual field defect will appear, and the outer upper quadrant will be affected first, and the red visual field will be shown first. Later, when the lesion increases and the compression is more severe, the white visual field is also affected, and gradually the defect can be expanded to bilateral temporal hemianopia. If left untreated, the visual field defect can be further enlarged and the visual acuity can be diminished to total blindness. Because pituitary tumors are mostly benign, the initial lesions can last for a considerable period of time, but when the disease is serious, the visual field impairment can suddenly increase, and if the tumor is on one side, it can lead to monocular blindness or blindness. If the tumor grows posteriorly and presses on the pituitary stalk or hypothalamus, it may cause polyuria; if the tumor grows laterally and encroaches on the wall of cavernous sinus, it may cause nerve palsy of motoneurotic nerve or abducens nerve; if the tumor grows upward through the saddle septum to the ventral part of frontal lobe, it may cause psychiatric symptoms; if the tumor grows posteriorly and obstructs the anterior part of the third ventricle and interventricular foramen, it may cause headache and vomiting and other intracranial symptoms; if the tumor grows posteriorly and obstructs the anterior part of the third ventricle and interventricular foramen, it may cause headache and vomiting. If the tumor grows posteriorly and obstructs the anterior part of the third ventricle and interventricular foramen, headache, vomiting and other symptoms of increased intracranial pressure will appear. Endocrinological examination: The growth hormone, prolactin, adrenocorticotropic hormone, thyroid-stimulating hormone, melanin-stimulating hormone, follicle-stimulating hormone and luteinizing hormone of pituitary gland are directly measured by endocrine radioimmuno-ultra-microscopic method, which is helpful for the early diagnosis of pituitary adenoma. Radiological examination 1.Pteroid saddle image: It is one of the basic examinations. When the pituitary adenoma is small, there can be no change in the saddle, but as the tumor grows, it can lead to enlargement of the saddle, bone destruction and saddle back erosion. 2.CT scan: After enhancing with intravenous contrast, it can show pituitary adenoma of 5mm size. Smaller tumors are still difficult to show. 3.MRI scan: Dynamic scan of pituitary gland is necessary in the diagnosis of pituitary microadenoma. A cranial X-ray, CT scan or MRI examination can help in the diagnosis of pituitary adenoma. Tomograms of the pterygoid saddle often show an enlarged saddle with thinning or destruction of the saddle base bone. Enhanced coronal, sagittal and axial CT scans can show the size of the tumor and its extension into the superior and inferior saddles and the pars interna, as well as the degree of pneumatization of the pterygoid sinus. The mri can show the tumor shape and its relationship with the surrounding structures more clearly, which is especially valuable for the diagnosis of pituitary microadenoma. According to the imaging examination, pituitary adenoma can be classified into five grades according to Hardy’s classification criteria, i.e. grade 1: the tumor is less than 10 mm in diameter and grows in the saddle; grade 2: the tumor extends up to 10 mm and fills the suprasellar pool; grade 3: the tumor extends 10 mm to 20 mm and elevates the third ventricle; grade 4: the tumor extends 20 mm to 30 mm and fills the anterior third ventricle. Grade 5: The tumor extends >30mm into the saddle and reaches the foramen magnum of the lateral ventricle, often combined with obstructive hydrocephalus. Grade 1 of this classification is microadenoma, grades 2 and 3 are macroadenoma, and grades 4 and 5 are giant adenoma. Diagnosis The diagnosis of pituitary adenoma is mainly based on the patient’s clinical presentation, visual field disorders and other neurological findings, as well as endocrinological and radiological examinations, etc. The diagnosis of a typical pituitary adenoma is not difficult. However, in early pituitary tumors with less obvious symptoms, the diagnosis is not easy or even undetectable. Differential diagnosis (1) Craniopharyngioma: It occurs mostly in children and young people, with slow onset. In addition to visual acuity and visual field disorders, it also shows signs of hypopituitarism and subthalamic involvement such as obesity and urinary collapse, etc. Large tumors show symptoms of increased intracranial pressure. In most cases, the tumor has cystic changes and calcification. Most of the tumors are located in the suprasellar area and the pituitary tissue is in the base of the saddle. (2) Saddle node meningioma: It occurs mostly in middle-aged people, with slow progression and initial symptoms of progressive vision loss with irregular visual field deficit, headache, and insignificant endocrine symptoms. The imaging shows regular tumor morphology and obvious enhancement effect. The tumor is located in the suprasellar area and the pituitary tissue is in the intersaddle base. (3) Lasker’s cleft cyst: the age of onset is young, mostly without obvious clinical manifestations, a few appear endocrine disorders and vision loss. On imaging, small cysts are located between the anterior and posterior lobes of the pituitary gland, resembling a “three-piece” pie. In large cysts, the pituitary tissue is pushed into the inferior, anterior, and superior parts of the cyst. This disease is most likely to be misdiagnosed as a pituitary tumor. (4) Germ cell tumor: Also known as ectopic pineal tumor, it occurs mostly in children, with rapid progression, polyuria, precocious puberty, and wasting. The clinical symptoms are obvious. The lesions are mostly located in the suprasellar region, and the enhancement effect is obvious. (5) Optic cross glioma: It occurs mostly in children and young people, with headache and vision loss as the main manifestations. (6) Epithelioid cysts: they are common in young people, with slow onset and visual impairment, and low signal lesions on imaging. Treatment 1, treatment principles 1, surgery: preferred, with pituitary stroke should be emergency surgery. 2.Stereotactic radiosurgery: without intracranial pressure increase sign, tumor diameter <3cm can be considered γ-knife or X-knife treatment. 3.Radiation therapy: Tumor cannot be completely cut or cannot tolerate surgery. 4.Pharmacological treatment: those with hypopituitarism can be treated with drug substitution, and those with secretory adenoma can be treated with drugs that inhibit excessive secretion of pituitary hormones. 5. Prevention of infection, symptomatic treatment and treatment of complications. Second, the principles of medication 1, non-secretory functional adenoma to prednisone, cortisone, thyroxine tablets, methyltestosterone, posterior pituitary hormone and other alternative treatment to improve hypopituitarism, according to the needs of the disease selection. Bromocriptine is suitable for PRL adenoma and GH adenoma, cycloheximide is suitable for ACTH adenoma and GH adenoma, and aminoglutethimide is suitable for ACTH adenoma. It is often used as an adjuvant drug after surgery or radiotherapy. 3. Correct cerebral edema and lower intracranial pressure with mannitol, tachyphylaxis and dexamethasone as the main drugs, and even human albumin can be used. 4.Pay attention to electrolyte and fluid balance, and replenish blood loss intraoperatively. 5, postoperative use of antibiotics to prevent infection as appropriate, can be combined with drugs; use neurotrophic drugs to promote brain cell recovery. 6.Treat symptomatically, and select drugs to deal with complications. Microsurgical treatment of pituitary adenoma through the nasal pterygoid sinus The operation is performed under general anesthesia, with the patient in the prone position, head tilted back at 30°, and the anesthetic cannula of the trachea fixed at the left corner of the mouth. Intraoperatively, the pterygoid sinus and saddle base bones were opened using deep illumination with a cold light source and a high-speed micro-abrasive drill. After entering the pterygoid saddle, the tumor was separated and removed under surgical microscopy. The pituitary microadenoma tissue is mostly white or purplish red in color and is easy to peel and remove. For large adenomas or giant adenomas, after removing the tumor tissue in the saddle, in order to obtain complete removal of the tumor protruding into the saddle, saline is slowly injected into the catheter preplaced in the subarachnoid space of the patient's lumbar region, and the intracranial pressure is increased to squeeze the suprasellar tumor into the operative field, which is conducive to surgical removal. The amount of saline injection depends on the monitored intracranial pressure value, generally 20ml-60ml, a few are 80ml. If the icp>5.33kpa, special caution should be taken, too much or too fast injection may produce acute intracranial pressure increase and cause serious complications. After tumor resection, hemostasis was tightly applied and the tumor cavity was blocked with small pieces of gelatin sponge. And take small pieces of muscle and bone pieces to perform saddle base repair, local then use medical adhesive to reinforce to prevent csf leakage or pituitary dislocation, nasal cavity is blocked with iodoform or oil sand strip. Note Pituitary adenoma is a benign tumor, early diagnosis and treatment is effective. Chronic headache with progressive vision loss, visual field defects and endocrine changes should be considered as a possible disease and should be seen by a specialist. The more serious the preoperative visual acuity is, the less likely it is to recover after surgery, so early diagnosis and treatment is the key, and it is also a prerequisite to strive for selective total resection. A rapid decrease in visual acuity within a short period of time indicates the possibility of pituitary stroke, and once diagnosed, urgent surgery is needed to save vision. Long-term follow-up is required after surgery, and reoperation can be considered for recurrence. x- or gamma-knife can be avoided for those with indications, but it is more expensive and cannot avoid the possibility of recurrence. Pituitary microadenomas (<10 mm in diameter) can be treated with bromocriptine. Generally, postoperative treatment with radiotherapy or medication is satisfactory. (1) You can drink and eat the next day after surgery, and you can walk on the ground the next day, and you are usually discharged from the hospital on the 4th to 6th day. (2) It is advisable to eat easily digestible food within one month after surgery, and pay attention to dietary hygiene, prohibit overeating and alcohol consumption. (3) Rest for one month after surgery, forbid to do strenuous exercise; forbid to have intercourse within 2 months; forbid to get pregnant within 3 months. (4) Postoperative recuperation should be in a quiet environment and avoid contact with too many people or mental work. Complications Complications such as hemiplegia, aphasia, thirst, polyhydramnios, polyuria, etc. may occur if the tumor grows and presses into the adjacent area.