eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Nasal and Sublabial Approaches to the Pituitary

Author: Howard S Kotler, MD, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago
Contributor Information and Disclosures

Updated: Jun 30, 2009

Introduction

The transnasal-sublabial approach to the pituitary has undergone an evolutionary refinement and today remains probably the most commonly used approach to selected pituitary tumors. The following article describes the history, technique, and complications of this useful surgical approach.

History of the Procedure

The evolution of the transnasal-transseptal approach to the pituitary traces its lineage and subsequent reintroduction to sequential developments in rhinosurgical and neurosurgical techniques.

In 1909, Hirsch combined the septal-submucous resection (as reported by Killian and Hajek's sphenoid sinusectomy) into a submucosal-septal approach to the sphenoid.1 Halstead first described using a gingivolabial incision to approach the septum, incorporating the upper lip and nose as a composite flap.2 In 1914, Cushing combined the gingivolabial incision and submucous resection as an approach to the pituitary.3 However, Cushing eventually abandoned the transseptal procedure, citing the high risk of intracranial contamination that likely results from direct contamination by the nasal vault.

In Paris, Guiot reported success using the transseptal approach, following the influence of Cushing's pupil, Dott.4,5 Hardy subsequently reintroduced the transseptal procedure to North America.6 Combined with the advent of antibiotics, the use of intravenous steroids, and the technological advancements in the use of the operating microscope, the transseptal approach to the pituitary remains the most popular approach today.

The normal median sagittal nasal anatomy is shown in the image below.

Normal median sagittal nasal anatomy.

Normal median sagittal nasal anatomy.

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Normal median sagittal nasal anatomy.

Normal median sagittal nasal anatomy.


Indications

Pituitary adenoma (as seen in the image below)

Coronal and median sagittal images of pituitary a...

Coronal and median sagittal images of pituitary adenoma.

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Coronal and median sagittal images of pituitary a...

Coronal and median sagittal images of pituitary adenoma.


Relevant Anatomy

Embryology, development, and surrounding anatomy of the sphenoid sinus

The sphenoid sinus begins as an evagination of the sphenoethmoidal recess during the fourth month of fetal life. Following the third year of life, the sinus begins to excavate into the pneumatizing sphenoid bone. This process progresses in the child from age 5-7 years. The adult size is not reached until age 18 years.

The extent of pneumatization by the sinus into the sphenoid bone varies greatly. The capacity of the sinus varies from 0.5-30 mL. Hamberger in 19617 and Congdon in 19308 classified 3 differing types of sella pneumatization, and each is conceptualized by the position in relation to the sella turcica. The presellar type (23%) has its posterior wall in contact with the anterior face of the sella. The sellar or postsellar type (67%) appears when the sinus extends posteriorly beyond the sella to the pons. The conchal type (5%) is similar to the presellar type, except that the most posterior part of the sinus is well anterior to the sella turcica.

The paired sphenoid sinuses rarely are symmetrical in size and have an intersinus septum that may be near horizontal in its orientation. This position renders the 2 sinuses in an over and under orientation, rather than in a lateral orientation. Important central nervous system, neurologic, and vascular structures surround the sphenoid sinus. Superiorly, the middle cranial fossa and the pituitary gland are in approximation to the sinus, while anterosuperiorly, the optic nerve and chiasm lie over the sinus. Anteriorly, a lateral margin of the sphenoid bone forms a portion of the posterior orbital wall, and the anterior sphenoid forms a crest that articulates with the perpendicular plate of the ethmoid bone.

The sphenoid ostia are located above the superior turbinate at approximately one-half the length from the anteroinferior-most border of the sinus. The ostia drain into the posterior aspect of the sphenoethmoidal recess. Laterally, the carotid artery may indent the sinus wall posteroinferiorly or even lie within the sinus, directly contacting the sinus mucosa. Likewise, the contents of the cavernous sinus, including the oculomotor, trochlear, and abducens nerves and the ophthalmic and maxillary branches of the trigeminal nerve, contact the lateral wall of the sinus. Inferiorly, the roof of the nasopharynx and the neurovascular anatomy of the pterygoid canal are found. The inferior surface forms the sphenoid rostrum and articulates with the vomer bone. Posteriorly, through the thick bony wall, the pons and basilar artery are located.

Contraindications

Contraindications to the transseptal-sublabial approach to the pituitary include the following:

  • Ongoing sinusitis that is untreated by either surgery and/or medical therapy
  • Highly vascular lesions
  • Dural-based lesions with a high risk for intraoperative and postoperative cerebrospinal fluid leak
  • Lesions with extensive suprasellar extension and carotid artery anatomy, wherein the arteries project into the sphenoid sinus and limit safe access

More on Nasal and Sublabial Approaches to the Pituitary

Overview: Nasal and Sublabial Approaches to the Pituitary
Workup: Nasal and Sublabial Approaches to the Pituitary
Treatment: Nasal and Sublabial Approaches to the Pituitary
Multimedia: Nasal and Sublabial Approaches to the Pituitary
References
Further Reading
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References

  1. Hirsch O. Eine neue methode der endonasalen operation von ypophysentumoren. Wien Med Wochenschr. 1909;59:636-638.

  2. Halstead AE. Remarks on the operative treatment of tumors of the hypophysis: with a report of two cases operated on by an oro-nasal method. Surg Gynecol Obstet. 1910;10:494-502.

  3. Cushing H. Surgical experiences with pituitary disorders. JAMA. 1914;63:1515-1525.

  4. Guiot G. Indications for the trans-sphenoidal approach of the hypophyseal fossa. Rhinol. 1973;11:137-152.

  5. Dott N, Bailey A. A consideration of the hypophysial adenomata. Br J Surg. 1925;13:314-366.

  6. Hardy J. Transsphenoidal hypophysectomy. J Neurosurg. Apr 1971;34(4):582-94. [Medline].

  7. Hamberger CA, Hammer G, Norlen G, Sjogren B. Transantrosphenoidal hypophysectomy. Arch Otolaryngol. Jul 1961;74:2-8. [Medline].

  8. Congdon ED. The distribution and mode of origin of septa and walls of the sphenoid sinus. Anat Rec. 1930;18:97.

  9. Duz B, Harman F, Secer HI, Bolu E, Gonul E. Transsphenoidal approaches to the pituitary: a progression in experience in a single centre. Acta Neurochir (Wien). Nov 2008;150(11):1133-8; discussion 1138-9. [Medline].

  10. Neal JG, Patel SJ, Kulbersh JS, Osguthorpe JD, Schlosser RJ. Comparison of techniques for transsphenoidal pituitary surgery. Am J Rhinol. Mar-Apr 2007;21(2):203-6. [Medline].

  11. Er U, Gürses L, Saka C, Belen D, Yigitkanli K, Simsek S, et al. Sublabial transseptal approach to pituitary adenomas with special emphasis on rhinological complications. Turk Neurosurg. Oct 2008;18(4):425-30. [Medline].

  12. Gammert C. Rhinosurgical experience with the transseptal-transsphenoidal hypophysectomy: technique and long-term results. Laryngoscope. Mar 1990;100(3):286-9. [Medline].

  13. [Guideline] Cook DM, Ezzat S, Katznelson L, Kleinberg DL, Laws ER Jr, Nippoldt TB, et al. AACE Medical Guidelines for Clinical Practice for the diagnosis and treatment of acromegaly. Endocr Pract. May-Jun 2004;10(3):213-25. [Medline].

  14. Cook DM, Ezzat S, Katznelson L, Kleinberg DL, Laws ER Jr, Nippoldt TB, et al. AACE Medical Guidelines for Clinical Practice for the diagnosis and treatment of acromegaly. Endocr Pract. May-Jun 2004;10(3):213-25. [Medline].

  15. Cushing H. Partial hypophysectomy for acromegaly. Ann Surg. 1909;50:1002.

  16. Dew LA, Haller JR, Major S. Transnasal transsphenoidal hypophysectomy: choice of approach for the otolaryngologist. Otolaryngol Head Neck Surg. Jun 1999;120(6):824-7. [Medline].

  17. Hollinshead WH. Anatomy for Surgeons. 3rd ed. Philadelphia, Pa: Harper & Row;1982:255-259.

  18. Koltai PJ, Goufman DB, Parnes SM, Steiniger JR. Transsphenoidal hypophysectomy through the external rhinoplasty approach. Otolaryngol Head Neck Surg. Sep 1994;111(3 Pt 1):197-200. [Medline].

  19. Sawyer R. Nasal approach to the sphenoid sinus after prior septal surgery. Laryngoscope. Jan 1991;101(1 Pt 1):89-91. [Medline].

  20. Schoem SR, Khan A, Wilson WR, Laws ER. Minimizing upper lip and incisor teeth paresthesias in approaches to transsphenoidal surgery. Otolaryngol Head Neck Surg. Jun 1997;116(6 Pt 1):656-61. [Medline].

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Further Reading

Clinical guidelines
American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of acromegaly. 13
American Association of Clinical Endocrinologists - Medical Specialty Society
American College of Endocrinology - Medical Specialty Society.  2004 May/June.  13 pages.  NGC:003789

ACR Appropriateness Criteria® neuroendocrine imaging.
American College of Radiology - Medical Specialty Society.  1999 (revised 2006).  11 pages.  [NGC Update Pending] NGC:005121

Clinical trial
A Study Examining the Peri- and Post-Operative Dynamics of the Growth Hormone (GH) - IGF-1 Axis in Subjects With Acromegaly During the First Year After Surgical Resection


Related eMedicine topics

 Sinusitis, Sphenoid, Acute, Surgical Treatment

Pituitary Tumors

Pituitary Adenoma

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Keywords

nasal and sublabial approaches to the pituitary, transnasal-sublabial approach to the pituitary, transnasal-transseptal approach to the pituitary

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Contributor Information and Disclosures

Author

Howard S Kotler, MD, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago
Howard S Kotler, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Physician Executives, American Medical Association, American Medical Informatics Association, Chicago Medical Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Eric J Moore, MD, FACS, Residency Director, Assistant Professor, Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Graduate School of Medicine
Eric J Moore, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, and American Rhinologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Karen Hall Calhoun, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, The Ohio State University
Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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