Nasal and Sublabial Approaches to the Pituitary Treatment & Management
- Author: Howard S Kotler, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA more...
The external rhinoplasty, transnasal transseptal, and transnasal sublabial approaches are described below. The external rhinoplasty and transnasal approaches do not incorporate a sublabial incision; however, the transnasal sublabial approach does.[9, 10]
External rhinoplasty approach
The external, or open, rhinoplasty approach for cosmetic or reconstructive rhinoplasty has been used effectively in transsphenoidal hypophysectomy. Proponents of the external approach described its unique ability to provide direct exposure to the sphenoid rostrum because, unlike the sublabial approach, the overhanging lip obstruction is not present. Moreover, because no oral incision is used, the external approach doesn't alter the gingivobuccal sulcus, which can impede the use of dentures. In addition, without superiorward elevation of the lip, upper lip paresthesia does not develop.[11, 12]
Furthermore, because no lateral dissection is necessary over the pyriform aperture or resection of the maxillary spine or crest, incisor teeth paresthesia is less likely. Other potential advantages include avoiding contamination from the oral cavity and avoiding bleeding from the sublabial sulcus. Complications unique to the external approach include the prolonged induration and edema of the nasal tip and an almost imperceptible columellar scar.
The open rhinoplasty approach incorporates the same surgical maneuvers as a cosmetic or reconstructive procedure. Prior to injection with a local anesthetic that contains a vasoconstrictor agent, the columellar incision is marked in an inverted gull-wing configuration. Anesthetic agent is also injected into the vestibular skin just superior to the most caudal margin of the lower lateral cartilage, the vestibular skin adjacent to the intermediate crus and site of the columellar incision, and the interdomal area.
The septum is also injected in a submucoperichondrial plane on both sides to include the vomer and perpendicular plate of the ethmoid bone. After 10 minutes, a #11 scalpel blade is used to incise the columellar skin in the previously marked site. When making this incision, note that the skin overlying the anterior face of the columella is extremely thin and care must be taken not to incise the most caudal margin of the lower lateral cartilage medial crus. Separate incisions are then made on the vestibular skin along the length of the lower lateral cartilage that connects the columellar incisions to the domal region.
Dissection is then carried superiorly in a plane immediately superficial to the lower lateral cartilage until the domal region, and only laterally over the most caudal margin of the lower lateral cartilage as necessary to gain access to the nasal tip. The interdomal ligaments are divided and the anterior septal angle and caudal end of the quadrangular cartilage are then visualized. The mucoperichondrial flaps are then elevated on either side of the quadrangular cartilage from the caudal margin of the cartilage to the perpendicular plate of the ethmoid bone and vomer. If the neurosurgeon needs cartilage, it is harvested while a 1-cm continuous cartilaginous dorsal and columellar strut is maintained. Further cartilage, vomer, and the perpendicular plate of the ethmoid bone is resected to visualize the sphenoid rostrum, and any remaining cartilage on the maxillary crest is removed to allow neurosurgical speculum placement.
Because the open rhinoplasty approach necessarily relies on the disruption of normal structural nasal support mechanisms, these must be reconstituted at the end of the procedure. Chief among these anatomic supports that require reconstitution include the interdomal ligaments and the support provided by the columella. At minimum, a 5-0 polydioxanone (PDS) suture should be used to reconstruct the interdomal ligaments with a portion of cartilage from the quadrangular cartilage used as a columellar strut. Final closure of the columellar incision is initiated using a single deep 5-0 PDS suture followed by interrupted 7-0 nylon skin sutures. All endonasal incisions are then closed with interrupted 4-0 chromic suture. Silastic septal splints are then applied to each of the mucoperichondrial planes with a running 4-0 nylon suture.
Transnasal transseptal approach
Unlike the external rhinoplasty approach, the transnasal transseptal approach requires no external columellar incision. Instead, a hemitransfixion incision is made, and the right and left mucoperichondrial flaps are then elevated over the quadrangular cartilage and perpendicular plate of the ethmoid and vomer bones. The mucoperichondrial flaps are elevated continuously with the mucoperiosteal flaps onto the floor of the nose. While maintaining a 1-cm–wide continuous dorsal and caudal cartilaginous strut, a portion of the quadrangular cartilage is resected and subsequently used to close the sphenoid defect. The caudal cartilaginous strut is then disarticulated from the maxillary crest and displaced laterally. Further ethmoid and vomer bone is resected with any remaining cartilage on the maxillary crest to allow sphenoid rostrum visualization. If exposure is limited because of a small nasal aperture, a unilateral alotomy can be made ipsilateral to the side of speculum placement.
A retrospective study by Fujimoto et al indicated that in an endoscopic transnasal transeptal approach to pituitary adenomas, use of a pedicled nasoseptal flap is an effective means of skull base reconstruction, for the prevention of a postoperative cerebrospinal fluid fistula.
A retrospective study by Hong et al indicated that transnasal transeptal microscopic pituitary surgery produces olfactory results comparable to those of endoscopic binostril surgery, while offering better anterior skull base nasal inventory outcomes in the early postoperative period, particularly with regard to nasal crusting and nose-blowing urge.
Transnasal-sublabial approach to the sphenoid sinus
The operation may be conceptualized as having nasal, septal, and oral portions, with the nasal surgical procedure performed before the oral portion. For the nasal septal portion of the operation, 2 separate approaches are described. One approach elevates the mucoperichondrium from both right and left faces of the septum, vomer, and perpendicular plate of the ethmoid bone, with subsequent harvest of a defined piece of quadrangular cartilage. The other approach leaves mucoperichondrium attached to one side of the cartilage to create a composite mucoperiosteal-quadrangular flap that is displaced laterally.
The patient is placed supine on the operating room table, and a Mayfield headrest is applied. The neurosurgeon should assist the otolaryngologist in defining the head position to avoid further unnecessary manipulation of the patient's cranium. Subsequently, neurosurgical pledgets containing 4% cocaine are placed into each nasal vault, with 1 in the sphenoethmoidal recess and the others overlying the middle and inferior turbinates. Local anesthetic consisting of 1% lidocaine containing 1:100,000 epinephrine is injected bilaterally into the nasal-septal submucoperichondrial plane, the subperiosteal plane of the vomer, and the perpendicular plate of the ethmoid bone. The lidocaine is also injected bilaterally into the floor of the nose and into the gingivolabial sulcus anteriorly between the canine teeth.
The eyes are covered with a transparent occlusive dressing that allows visualization of the periorbita and palpation of the globe during the procedure. The head and face are draped, and the eyes, nose, and mouth remain exposed. The cocaine pledgets are removed, and the first incision is made.
The surgeon performing the operation, not the neurosurgeon, should explain the risks and complications of the transnasal-sublabial approach in detail. The most common risks and complications of the procedure include the following:
Marked edema and cosmetic deformity of the midface, which may last up to 6 months or be permanent in nature
Decreased sensation over the entire mid face and/or teeth, which may last up to 6 months or be permanent in nature
Cosmetic deformity of the external nasal skeleton, which may require further cosmetic and reconstructive surgery
Difficulty breathing through the nose, which may require further reconstructive surgery and may be permanent in nature
Nasal-septal perforation, which may require further reconstructive surgery and may be permanent in nature
Chronic nasal dryness and/or bleeding
Complete or partial loss of the sense of smell
Cerebrospinal fluid leak, which may require further surgery to correct
Double vision or complete blindness, which may be temporary or permanent in nature
Complete or partial loss of skin over the mid face, which may require further reconstructive surgery
Complete or partial breakdown of the gingivolabial incision requiring additional oral surgical procedures
Injury to the gingiva requiring extensive oral surgical reconstructive surgery
Difficulty wearing oral appliances (eg, dentures) after healing is complete, which may necessitate revision of the appliances or reconfiguration of new appliances
The median, sagittal, and coronal anatomy is represented in the images below and is the orientation for the following discussion.
Approach with cartilage removal
The neurosurgeon often requires a portion of quadrangular cartilage to reconstruct the sphenoid. The procedure is initiated with a hemitransfixion incision made into either the right or left mucoperichondrial plane and carried down to the level of the septal cartilage as seen in the image below. This submucoperichondrial plane develops and is elevated from the quadrangular cartilage to its junction with the vomer and the perpendicular plate of the ethmoid bone. Inferiorly, this plane attaches to the maxillary crest and elevates from the nasal floor. Through the same incision caudally, the contralateral mucoperichondrial plane is elevated from underlying structures as mentioned above.
An incision is then made into the cartilage in a continuous L-shaped configuration, while maintaining a 1-cm width in both caudal and dorsal dimensions. The cartilage is removed using a swivel knife and cleanly excised from its junction at the perpendicular ethmoid bone, vomer, and maxillary crest and spine. Thus, a significant portion of quadrangular cartilage may be harvested as long as the remaining portion is one continuous piece that is 1 cm in dorsal and caudal width and remains attached to the keystone area (attachment of quadrangular cartilage to nasal bone pyramid) under the caudal edge of the nasal bone.
If the remaining strut of cartilage is detached from this critical site, the cartilage must be sutured back into position. Failure to permanently maintain this support is likely to result in a saddle-nose deformity. Finally, if the neurosurgeon does not use this portion of harvested cartilage in its entirety to reconstruct the sphenoid, then the cartilage may be replaced between the mucoperichondrial layers prior to closure.
Following removal of a portion of cartilage, the fibrous adhesion between the septal mucoperichondrial plane and the maxillary crest may be carefully incised with the sharp end of a Cottle or Freer elevator. A submucoperiosteal plane is then developed onto the floor of the nose. The same technique is performed on both sides, such that one continuous flap is developed on each side that begins superiorly near the dorsum and ends subperiosteally on the floor of the nose as seen in the image below. Alternatively, the nasal floor submucoperiosteal plane may be developed after making the gingivolabial incision. In this case, carefully dividing the fibrous attachments between the nasal floor submucoperiosteal flap and the septal mucoperichondrial flaps at the maxillary crest may serve to connect these flaps.
Approach without cartilage removal
If cartilage harvest is not anticipated, then elevation of the mucoperichondrial plane is initiated on only one side of the cartilaginous septum. Elevation is carried out over the ipsilateral face of the vomer, the perpendicular ethmoid bone, and inferiorly to the maxillary crest. The dissection is carefully carried through the fibrous attachments at the maxillary crest and onto the ipsilateral floor of the nose as seen in the image below, elevating a submucoperiosteal plane. Thus, a flap is created on one side that includes in continuity both the septal mucoperichondrial and nasal floor mucoperiosteal flaps.
Through the preexisting hemitransfixion incision, an inferior tunnel is created in the nasal floor on the contralateral side. This tunnel extends laterally from under the inferior turbinate to the maxillary crest medially. The tunnel extends anteriorly from the nasal aperture to nearly the posterior end of the hard palate. This is represented in the image below.
A vertical incision is made into the quadrangular cartilage, making certain that a significant portion of cartilage remains attached to the perpendicular plate of the ethmoid bone and the underside of the nasal bones in the keystone region. Failure to maintain these attachments allows the inferior displacement of the cartilaginous dorsum, which results in a saddle-nose deformity. A long-blade nasal speculum is inserted between the continuous mucoperichondrial and mucoperiosteal flaps, and the fibrous attachments between the maxillary crest and septal cartilage are divided. Use particular care when the cartilage is dissociated from the maxillary crest and when connecting the composite flap with the contralateral nasal floor mucoperiosteal flap. The cartilage is dissociated from its bony attachments at the vomer. The perpendicular plate of the ethmoid bone, the maxillary crest, and the composite flap are then mobilized laterally into the same nasal vault. This is represented in the image below.
The speculum is placed into the posterior cartilaginous incision. After inferior and superior vomer and perpendicular plate bony cuts are made with septal scissors, the perpendicular plate of the ethmoid bone and vomer are removed with a Takahashi or Jansen-Middleton forceps. The bone is removed until the sphenoid rostrum is exposed.
Modified approach for narrow space
Takemura et al described a modified transnasal transseptal approach to pituitary lesions, a two-surgeon, four-handed technique for use in patients with a narrow nasal space. In this procedure, a transseptal route was taken through one nostril, with an endoscopic septoplasty technique employed to remove the nasal septum; a transnasal approach was used via the other nostril, with no pedicled nasoseptal flap harvested on that side. However, the surgeons preserved the transnasal-side mucosa containing the septal branch of the sphenopalatine artery located over the face of the sphenoid and nasal septum; in this way, a nasoseptal flap could be harvested if an intraoperative cerebrospinal fluid leak occurred. The modified procedure was carried out on six patients, each of who had a pituitary lesion (nonfunctioning macroadenoma, Rathke cleft cyst, or growth hormone-producing macroadenoma), as well as a severely deviated nasal septum and/or narrow nasal space. The operations were performed without surgicalcomplications.
Oral surgical procedure
The nasal speculum is removed, and attention is directed to the gingivolabial sulcus. An incision is made in the sulcus approximately 1 cm superior to the gingival margin between canine fossae. Gingivolabial incision is depicted in the image below.
Double pronged hooks or a wide rake are then placed in this gingivolabial incision, and dissection is carried superiorly in a subperiosteal plane to the pyriform aperture. Next, careful dissection occurs at the inferior most margin of the pyriform aperture, and the mucoperiosteum is elevated bilaterally off the floor of the nose. The mucoperiosteum sweeps laterally under the inferior turbinates and posteriorly to the midnasal floor. Any attachments of the caudal septum with the maxillary spine are divided in the process.
Exposure of sphenoid rostrum
- A neurosurgical speculum is inserted through the sublabial incision, as seen in the image below, between the septal mucoperichondrial mucosal flaps (or in between the septal mucoperichondrial and composite septal flaps in the instance where cartilage is not harvested).
- The speculum is advanced superiorly to the level of the well-exposed sphenoid rostrum. Wide exposure of the rostrum is best achieved with a neurosurgical speculum that has flanged blade tips because these tips push the previously elevated sphenoid rostrum mucoperiosteum laterally. The blades of the speculum are then opened widely, and intraoperative fluoroscopic radiography confirms the correct position of the speculum. The remaining portions of vomer and ethmoid bone are removed, which allows the speculum to contact the sphenoid rostrum as seen in the image below.
- With the radiographic confirmation of the proper speculum position, an osteotome and Gay-Kerrison rongeur are used to enter the sphenoid sinus in the midsagittal plane. Careful removal of the rostrum is performed to achieve a full view of the sphenoid sinus. With the sphenoid sinus opened, the remainder of the operation is turned over to the neurosurgeon.
Approach after previous nasal-septal surgery
Patients who have planned sublabial-transphenoidal surgery often have had previous nasal-septal, maxillary, or sinus surgical procedures. The concern is that clean dissection between tissue planes may be difficult or impossible because the surgeon encounters a large amount of scar tissue. This concern especially is relevant when the patient has had previous septal surgery (eg, submucous cartilage resection, or septoplasty). Careful dissection between mucoperichondrial planes can be difficult, if not impossible. A number of possible alternatives exist for the patient that has had previous septal surgery. Conceptually, the surgeon may carefully dissect through or around the cicatrix or laterally displace the septum to expose the sphenoid rostrum. Each approach is considered individually below.
Dissection through previous cicatrix: Following a carefully executed hemitransfixion incision, difficult dissection through adherent mucoperichondrial planes can be facilitated with a narrow-width long-bladed nasal speculum. After establishing a dissection plane anteriorly between mucoperichondrial planes, this speculum is carefully insinuated. Both blunt and sharp dissection take place under well-lit direct visualization to meticulously dissect the planes. This is one dissection that relies on absolute visualization and not on the feel between planes. Often, if the dissection becomes nearly impossible because of densely adherent tissue planes, redirecting the dissection to a more superior or inferior plane reveals a place to reestablish the dissection.
Dissection around the cicatrix: Using a hemitransfixion incision, unyielding adherent mucoperichondrium may be dissected free over or under the cicatrix to arrive at the sphenoid rostrum. The adherent mucoperichondrium often exists in multiple regions, which contributes to inadequate neurosurgical exposure. The open or external rhinoplasty approach is advocated when multiple sites of cicatrix limit the safe and adequate dissection between mucoperichondrial planes.
Lateral dislocation of the septum:
- Lateral dislocation of the septum is a third alternative when other techniques cannot be used because the mucoperichondrial planes are sufficiently adherent or when the risk that a significant septal perforation may occur following attempted dissection is too great. In this technique, an incision is made along the nasal floor, as seen in the image below, just under the inferior turbinate. The incision extends from the pyriform aperture to the junction of the hard and soft palate.
- The mucoperiosteum is elevated to the maxillary crest, and the attachments between the septum and maxillary crest are divided. This incision is then connected anteriorly to almost the entire circumference of a full transfixion incision. This is represented in the image below.
- As the septal flap is dislocated laterally into the contralateral nasal vault, a vertical incision is made through the mucosa overlying the vomer bone, and the midline is identified inferior to the floor of the sphenoid bone. Through this opening, the sphenoid rostrum is identified. After the sublabial flap is elevated, the septal flap is dislocated laterally, the neurosurgical speculum is inserted up to the level of the sphenoid rostrum, and entrance is made into the sphenoid sinus.
Closure of nasal-septal and oral incisions
The nasal portion of the closure precedes the oral closure. Fixing the anterior-inferior septal cartilaginous strut to the maxillary spine with 4-0 PDS suture initiates nasal closure. Often, the maxillary spine and large portions of the maxillary crest have been resected to obtain superior visualization of the sphenoid rostrum, leaving little bony or durable soft tissue with which to affix suture. In these cases, the septal cartilage may be sutured instead to the soft tissues of the columella. Cartilage strips may also be used as a columellar strut to add support and prevent postoperative nasal tip ptosis.
The hemitransfixion incision is closed with a continuous running 4-0 chromic suture, and the mucoperichondrial flaps are reapproximated with silastic splints. The splints are placed one on each side and are quilted together using a 4-0 nylon suture. The nasal vault is packed on each side with a nonabsorbable sponge coated with antibiotic ointment. The sponge is removed on the fourth postoperative day. The gingivolabial incision is then closed using both deep and mucosal interrupted 3-0 chromic sutures.
Nasal packing and septal splints are removed in the first week postoperatively. Patients are reminded to use an intranasal saline mist 4-6 times per day for 2-3 weeks postoperatively to minimize intranasal crusting.
The otolaryngologist-head and neck surgeon evaluates the patient postoperatively at weekly intervals for a total of 4 visits. This schedule allows for thorough clearing of nasal crusting and obstruction under direct visualization.
The oral and rhinologic sequelae and complications arising from the sublabial-transseptal approach to the sphenoid essentially are the same as those for any gingival and septal surgery. These complications can be conceptualized separately as those arising from the nasal and those arising from the oral surgical portions of the procedure.
Perhaps the most common complication is septal perforation. In 1990, Gammert conducted a 5-year follow-up study of patients undergoing either intranasal-transseptal or sublabial-transseptal approach and found a 12.4% perforation rate. This rate is significantly higher than the 5-8% reported in the rhinologic literature. Rhinologic studies report that patients with prolactinoma have a higher incidence of septal perforation than those with acromegaly. This difference is attributed to a difference in mucosal atrophy, a phenomenon observed in patients with pituitary gland dysfunction.
Mucosal dryness or nasal crusting was noted in 35.4% (n=113) of patients undergoing transnasal or translabial approaches. These patients required moistening ointments and nasal spray as therapy. Frank epistaxis is an infrequent complication of any approach to the sphenoid and, in one series, was observed in 3.5% of patients.
Oral surgical complications
Detractors of the sublabial approach mention the complication of upper lip, dental, and gingival hypesthesia. This hypesthesia presumably is the result of division of cranial nerve X as it courses through the incisive foramen and supplies the upper lip and central incisors. Injury to this nerve is likely to occur when the nasal spine is reduced in size or removed completely to better visualize the sphenoid rostrum. While some authors believe this complication is more likely to occur with the sublabial approach, it also is a likely complication of any transphenoidal approach when removal of the nasal spine is performed to better visualize the sphenoid rostrum. Return of partial or complete sensation is likely to occur by the sixth month postoperatively if it returns at all.
Division of the gingivolabial mucosa with subsequent cicatrix can impair proper fitting of dentures by fibrotic tissue obliteration. Explain to patients that, even after postoperative tenderness has resolved fully, dentures might require either adjustment or complete replacement to account for this change in anatomic contour.
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