Pituitary tumor is one of the common tumors in neurosurgery, accounting for 10-15% of total intracranial tumor incidence. There are many clinical procedures used for pituitary tumor resection, the earliest being craniotomy, and the last decade or so the transsphenoidal approach is a very common type of procedure, including transoral nasal butterfly approach, transnasal vestibular butterfly sinus approach, transseptal butterfly approach, and the modified single nostril direct butterfly sinus approach.
It can effectively remove pituitary adenomas in the saddle, protruding into the pterygoid sinus, extending in the form of a column towards the saddle and confined to the pterygoid sinus, without serious complications as long as it is performed properly. However, the access route with single nostril entry has a narrow surgical space, which requires precise positioning, delicate microsurgical instruments, and superb microsurgical techniques. For tumors that protrude into the cavernous sinus, they cannot be removed under direct vision, and can only be removed by the operator’s subjective senses. We analyzed the advantages and disadvantages of this method by surgically treating 30 patients with pituitary tumors, combining preoperative and postoperative imaging and endocrine examinations in order to better serve the patients.
II. Project size and general information: From 2001 to August 2005, 30 patients with pituitary tumors were treated in our department by direct single nasal aperture pterygoid sinus approach to remove the tumor, and the initial exploration of this approach was completed. There were 19 male cases and 11 female cases, aged 22-72 years, with a mean age of 47 years. The duration of the disease was 1 month-8 years, with an average of 1.9 years. The main clinical manifestations were: headache in 20 cases, menstrual disorders in 9 cases, decreased visual acuity in 10 cases, visual field defects in 8 cases, acromegaly in 4 cases, generalized weakness in 5 cases, confusion in 2 cases, vomiting in 2 cases, and urinary collapse in 3 cases. 12 cases had increased PRL, 6 cases had increased GH, 3 cases had increased ACTH, and 3 cases had hypothyroidism.
The cranial lateral X-ray was taken in 21 cases, and it was confirmed that there were 3 cases of saddle-occipital pterygoid sinus, 18 cases of full saddle pterygoid sinus, 8 cases of half saddle pterygoid sinus, 1 case of metachronous pterygoid sinus, and 22 cases of spherical enlargement of pterygoid saddle. The tumor invaded the spongy sinus and suprasellar pool in 8 cases and protruded into the pterygoid sinus in 2 cases.
According to the intraoperative microscopic observation and postoperative review of MRI, 22 cases were completely excised and 8 cases were mostly excised. Postoperative pathology confirmed 12 cases of PRL adenoma, 6 cases of GH adenoma, 3 cases of ACTH adenoma, and 9 cases of non-functional adenoma. Among them, 2 cases of PRL adenoma and 1 case of non-functional adenoma were pituitary tumor strokes.
Complications: 7 cases had postoperative transient uropathy, 5 cases improved after 4-5 days of subcutaneous injection of posterior pituitary hormone, 2 cases improved after 2 months of continued oral mydriasis, 1 patient had cerebrospinal fluid nasal leakage, and the symptoms disappeared after 1 week with cranial pressure lowering and symptomatic conservative treatment.
3. Follow-up: Postoperative follow-up ranged from 3 months to 4 years. All patients had their cranial MRI rechecked in about half a year, and there was no recurrence of tumor in 1 case. The hormone level of PRL adenoma was normalized in 7 cases, decreased by 50% in 4 cases, and decreased by 30% in 1 case. The hormone level of ACTH was in normal range after surgery, and GH adenoma was normalized in 5 cases and decreased by 50% in 1 case. Visual acuity review, 10 cases of visual acuity decline, 9 cases of visual acuity have been restored, 1 case of blindness patients did not significantly recover after surgery.
IV. Economic benefit index: This study is a clinical study, and each patient can create direct economic benefit to the hospital of RMB 4000 yuan on average, and 30 patients can create RMB 120,000 yuan. It also provides patients with a safe, minimally invasive, convenient and effective ideal treatment method.
V. Conclusion: Pituitary tumor is one of the common intracranial tumors in neurosurgery, with an incidence of about 1/100,000, accounting for 10%-15% of total intracranial tumor incidence, mostly seen in adults aged 30-50, and the pathogenesis is not fully understood. The pathogenesis is not fully understood. Except for PRL microadenoma, which can be treated with medication, surgery is mostly preferred. There are many clinical procedures for pituitary adenoma resection, each of which has its own indications, advantages and disadvantages. The transsphenoidal approach is one of the commonly used procedures, including the transoral nasopalatine approach, the transnasal vestibular pterygoid approach, and the transseptal pterygoid approach, of which the single nostril direct transsphenoidal approach is the most simplified one. It can effectively remove the pituitary adenoma which is protruding to the pterygoid sinus, extending in the form of a column towards the saddle and confined to the pterygoid saddle, without serious complications and without damage or pulling on the brain tissue.
At present, only our department performs this operation in the province. The operation is performed by unilateral nostril entry, which requires a small surgical space and delicate microsurgical instruments; for the tumor protruding to the cavernous sinus, it cannot be removed under direct vision because of the narrow field, and can only be removed by the feel of the scraping circle, which requires high subjective experience of the operator. With the application of neuroendoscopy, neuronavigator, Taichung MRI and ultrasound technology, the steps of removing tumor by subjective experience in this approach will definitely be improved, and accurate and minimally invasive removal of tumor is the inevitable trend.