The findings, published in the February 2003 edition of the peer-reviewed Journal of Neurosurgery, quantify the advantages of the direct endonasal approach over the sublabial procedure, regarded as the surgical standard for more than 40 years.
"Surgical standards, understandably, are slow to change. Yet our study suggests the direct endonasal approach to removing pituitary tumors offers a more direct surgical route with excellent tumor removal rates, a low complication rate and minimal post-operative discomfort," said Dr. Daniel Kelly, associate professor of neurosurgery at UCLA's David Geffen School of Medicine and director of the UCLA Pituitary Tumor and Neuroendocrine Program.
"Patients who, over time, have undergone both procedures overwhelmingly preferred the endonasal approach," said Kelly, who also directs the UCLA Pituitary Tumor and Neuroendocrine Program and co-directs the Harbor-UCLA Pituitary Center. "The endonasal method provides a simpler, more minimally invasive approach compared to the traditional sublabial procedure."
The study:
The study documented the post-operative complaints, tumor remission rates and surgical complications of 100 consecutive patients who underwent the endonasal procedure at UCLA Medical Center and at Harbor-UCLA Medical Center, a Los Angeles County hospital affiliated with UCLA's David Geffen School of Medicine. Seventy-eight patients completed questionnaires. Fourteen of the respondents had undergone a prior sublabial pituitary tumor removal procedure.
Among the findings:
- Study participants had remission rates across the various pituitary tumor sub-groups comparable to those found in past studies of sublabial patients. They also had similar rates of hormonal gain and loss.
- Twelve of 14 patients (86 percent) with prior sublabial surgery preferred the endonasal approach in terms of pain and ease of recovery.
- The most common post-surgical complaints involved nasal packing (30 percent), removal of packing (36 percent), and mouth breathing (35 percent). (Given the minimal incision and frequency of complaints, use of packing is no longer used for this procedure at UCLA.)
- At three months or more after surgery, patients quantified sinus/nasal problems as follows: facial pain -- none (83 percent), severe (4 percent); nasal congestion -- none (75 percent), severe (3 percent); decreased nasal airflow -- none (77 percent), severe (4 percent); decreased sense of smell -- none (73 percent), severe (4 percent); and upper lip numbness -- none (87 percent), severe (1 percent).
Other researchers involved in the project were Gabriel Zada, currently a medical student at UC San Francisco Medical Center; Dr. Pejman Cohan of the Geffen School of Medicine's Division of Endocrinology; and Dr. Christina Wang and Dr. Ronald Swerdloff of the Harbor-UCLA Medical Center and Research and Education Institute's Division of Endocrinology.
Pituitary tumor primer:
The pituitary is a small, bean-shaped gland located below the brain in the skull base. Often called the master gland, it controls the secretion of hormones. Hormones have a dramatic and broad range of effects on metabolism, growth and maturation, sexuality and reproduction, and other important bodily functions.
Pituitary tumors account for approximately 15 percent of primary brain tumors. Autopsy studies and magnetic resonance imaging show that up to 20 percent of the general population has a pituitary tumor.
Most are benign and relatively small growing, causing no significant harm or symptoms. Some, however, progress to cause major hormonal and neurological difficulties such as sexual dysfunction, abnormal growth, depression, headaches, impaired vision and even blindness. Up to 40,000 people nationwide have pituitary tumors removed each year.
The sublabial approach to removing pituitary tumors was first described in 1912, and by the 1960s had become the surgical standard. The approach involves an incision beneath the upper lip and extensive dissection in and around the nasal cavity. While proven safe and effective at removing the tumor, the procedure can cause long-term patient discomfort, including impaired nasal function and numbness of the upper lip and teeth.
The endonasal approach provides a simpler, more direct approach to the pituitary gland. A nasal speculum is passed directly into a nostril, providing a working corridor for all surgical instruments and the passage of light from the operating microscope or a surgical endoscope. An incision is made in the back of the nasal cavity to expose the pituitary glad. As with the sublabial approach, the procedure has proven safe and effective at removing the tumor.
Online resources:
Journal
Journal of Neurosurgery