Endoscopic Surgery for Pituitary Tumor is Performed Through the Nostril
May 01, 2009
When Adam Mamelak, M.D., a neurosurgeon at Cedars-Sinai Medical Center, removed a large tumor from the pituitary gland of his patient, Sharon Moreland, he took a surgical route that many surgeons follow but used a tool that most do not.
Mamelak inserted an endoscope--consisting of a camera lens at the tip of a long tube--through a nostril, entering the skull base through the sphenoid sinus, which is located deep within the skull and below the pituitary gland.
A decade ago, neurosurgeons removing pituitary tumors typically used a large, bulky surgical microscope and entered through an incision under the lip, which caused significant damage to nasal structures. Today, most surgeons use the nasal approach but continue to use the surgical microscope.
Mamelak, however, prefers the endoscopic approach because it is more maneuverable, reduces the patient's pain considerably, leaves no visible scars, and lowers some of the overall surgical risk. The nostril is a very narrow corridor through which to work, he explains, and the endoscope fits within it, providing a panoramic view of the surgical site.
In contrast, the microscope is larger and fixed, so the surgeon is working from a greater distance, through a very narrow cone, and trying to introduce instruments through the same corridor.
Over the past several years, Moreland experienced a variety of physical changes including tinnitus, joint pain, dry mouth and skin, enlarged hands and feet, and vision problems, but she always found a reasonable explanation for each new symptom. The ringing in her ears, for example, she attributed to the 15 years she and her family photographed off-road car and motorcycle races. She thought her hand and knuckle pain were caused by carpal tunnel syndrome and arthritis. But her deteriorating peripheral vision led to the discovery of the true diagnosis.
In January, Moreland, 68, who has four adult children and four grandchildren, scheduled an appointment with her ophthalmologist. The doctor ruled out glaucoma and cataracts but recommended that Moreland see her primary care physician, who ordered an MRI. The image showed a large tumor wrapping around her pituitary gland.
After conducting a full medical workup, Moreland's physician referred her to Mamelak, a neurosurgeon in the Department of Neurosurgery at Cedars-Sinai, who removed the benign tumor Feb. 24. She was released from the hospital-- tumor-free and with only minor nasal discharge-- two days later.
"Because there is so little tissue destruction with the endoscopic approach, we don't need to pack the nose after the operation to minimize bleeding and drainage. Patients are much more comfortable and very happy with the results," said Mamelak, who performs about 75 pituitary operations a year.
"The endoscope is especially advantageous in removing a very large, soft tumor like this where it is difficult but important to distinguish between the gland and the tumor," he added. "The endoscope's view stays wide, no matter how deep you go. In her case, the tumor extended far up and to the side, but the endoscope can be moved and tilted, which made it possible for us to remove the entire tumor."
Moreland's gradually worsening and wide-ranging symptoms had been the result of hormonal changes caused by the tumor's effect on the pituitary gland and the pituitary's control over the thyroid gland. Although removal of the tumor may be the only necessary treatment, lab tests will determine if a thyroid supplement may be added.
Within a week of the surgery, Moreland noticed that her symptoms were fading and she did not need the anti-inflammatory pain medications she had grown to depend on. "My joint aching has cut down to probably 65 percent, and my mouth has cleared up, my saliva is back, my skin is wonderful and I can see out of my eyes - on the side and everything," she said.