Removing pituitary tumors through the nasal cavity ratherthan using the classic approach beneath the upper lip offers patients aminimally invasive alternative with similar results, less discomfort and fasterrecovery, a new UCLA study indicates.
The findings, published in the February 2003 edition of thepeer-reviewed Journal of Neurosurgery, quantify the advantages of the directendonasal approach over the sublabial procedure, regarded as the surgicalstandard for more than 40 years.
"Surgical standards, understandably, are slow to change. Yetour study suggests the direct endonasal approach to removing pituitary tumorsoffers a more direct surgical route with excellent tumor removal rates, a lowcomplication rate and minimal post-operative discomfort," said Dr. DanielKelly, associate professor of neurosurgery at UCLA's David Geffen School ofMedicine and director of the UCLA Pituitary Tumor and Neuroendocrine Program.
"Patients who, over time, have undergone both proceduresoverwhelmingly preferred the endonasal approach," said Kelly, who also directsthe UCLA Pituitary Tumor and Neuroendocrine Program and co-directs theHarbor-UCLA Pituitary Center. "The endonasal method provides a simpler, moreminimally invasive approach compared to the traditional sublabial procedure."
The study documented the post-operative complaints, tumorremission rates and surgical complications of 100 consecutive patients whounderwent the endonasal procedure at UCLA Medical Center and at Harbor-UCLAMedical Center, a Los Angeles County hospital affiliated with UCLA's DavidGeffen School of Medicine. Seventy-eight patients completed questionnaires.Fourteen of the respondents had undergone a prior sublabial pituitary tumorremoval procedure.
Among the findings:
Study participants had remission rates across thevarious pituitary tumor sub-groups comparable to those found in past studies ofsublabial patients. They also had similar rates of hormonal gain and loss.
Twelve of 14 patients (86 percent) with prior sublabialsurgery preferred the endonasal approach in terms of pain and ease of recovery.
The most common post-surgical complaints involved nasalpacking (30 percent), removal of packing (36 percent), and mouth breathing (35percent). (Given the minimal incision and frequency of complaints, use ofpacking is no longer used for this procedure at UCLA.)
At three months or more after surgery, patientsquantified 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); decreasedsense 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. PejmanCohan of the Geffen School of Medicine's Division of Endocrinology; and Dr.Christina Wang and Dr. Ronald Swerdloff of the Harbor-UCLA Medical Center andResearch and Education Institute's Division of Endocrinology.
Pituitary tumor primer:
The pituitary is a small, bean-shaped gland located belowthe brain in the skull base. Often called the master gland, it controls thesecretion of hormones. Hormones have a dramatic and broad range of effects onmetabolism, growth and maturation, sexuality and reproduction, and otherimportant bodily functions.
Pituitary tumors account for approximately 15 percent ofprimary brain tumors. Autopsy studies and magnetic resonance imaging show thatup to 20 percent of the general population has a pituitary tumor.
Most are benign and relatively small growing, causing nosignificant harm or symptoms. Some, however, progress to cause major hormonaland neurological difficulties such as sexual dysfunction, abnormal growth,depression, headaches, impaired vision and even blindness. Up to 40,000 peoplenationwide have pituitary tumors removed each year.
The sublabial approach to removing pituitary tumors was firstdescribed in 1912, and by the 1960s had become the surgical standard. Theapproach involves an incision beneath the upper lip and extensive dissection inand around the nasal cavity. While proven safe and effective at removing thetumor, the procedure can cause long-term patient discomfort, including impairednasal function and numbness of the upper lip and teeth.
The endonasal approach provides a simpler, more directapproach to the pituitary gland. A nasal speculum is passed directly into anostril, providing a working corridor for all surgical instruments and thepassage of light from the operating microscope or a surgical endoscope. Anincision 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 atremoving the tumor.
David Geffen School of Medicine at UCLA: www.medsch.ucla.edu/
UCLA Division of Neurosurgery: www.neurosurgery.medsch.ucla.edu/
Pituitary Tumor and Neuroendocrine Program at UCLA: www.pituitary.ucla.edu/
Journal of Neurosurgery: www.thejns-net.org/