Long-term Recovery Patterns of Olfactory Function after Trans-sphenoidal Approach with Nasoseptal Flap Elevation

Abstract Introduction Nasoseptal flap is widely used in reconstruction of the skull base to prevent cerebrospinal fluid leakage after surgery for skull base lesions. There has been a debate on whether more severe olfactory dysfunction occurs after nasoseptal flap elevation than the conventional trans-sphenoidal approach. Objective To compare the long-term recovery patterns associated with nasoseptal flap and the conventional trans-sphenoidal approach. Methods The subjects were divided into the conventional trans-sphenoidal approach group and the nasoseptal flap elevation group. We followed up self-reported olfactory score using the visual analogue scale and threshold discrimination identification (TDI) score of the Korean Version of the Sniffin Stick test II for 12 months, with olfactory training. Results The study included 31 patients who underwent the trans-sphenoidal approach. Compared with preoperative status, the mean visual analogue scale and TDI scores in the conventional trans-sphenoidal approach group recovered 2 months postoperatively, while in the nasoseptal flap elevation group the visual analogue scale and TDI scores recovered 6 months and 3 months after surgery, respectively. Twelve months after surgery, the visual analogue scale and TDI scores in the conventional trans-sphenoidal approach group were 9.3 ± 0.5 and 28.5 ± 4.3, while those from the nasoseptal flap elevation group were 8.9 ± 1.5 and 27.2 ± 4.7 (p = 0.326; 0.473). Only one of the patients in the nasoseptal flap elevation group had permanent olfactory dysfunction. Conclusion The olfactory function recovered more gradually in the nasoseptal flap elevation group than in the conventional trans-sphenoidal approach group, but there was no difference between the two groups after 6 months.

Post-operative complications of Trans-Sphenoidal surgery in a local tertiary hospital during hospital stay

Introduction@#Endoscopic trans-sphenoidal surgeries are mainly the procedure of choice in pituitary adenomas with favorable results and varied outcomes arise from these techniques. The study aims to report the postoperative complications, and if these complications may have an impact on hospital stay.@*Methods@#This is a retrospective cross-sectional study. 47 patients were involved ages 19 years old and above who had trans-sphenoidal surgery (TSS) from January 2011 to December 2016. Data collected were focused on preoperative diagnosis and post-operative complications (prolonged intubation, post-operative vomiting, CSF leak, post-operative bleeding, adrenal insufficiency, diabetes insipidus, electrolyte imbalance). Chi-square and independent T-tests were used in this study.@*Results@#Most of the cases reported were nonfunctioning pituitary macroadenoma, prolactinoma and acromegaly. The study showed that the average length of stay of a patient who had undergone TSS is about seven days. Mean age of patients was 47 years old and 59% are males. The five most common complications while at hospital stay were headache (46%), throat irritation (38%), electrolyte imbalance (27%), SIRS (25%), and diabetes insipidus (10%). No sufficient evidence was appreciated with these complications comparing to the length of hospital stay.@*Conclusion@#Headache is the most common complication of post TSS. Comparing post-operative complications, it did not dictate the length of hospital stay.

Charles Bonnet Syndrome Following Trans-Sphenoidal Adenomectomy without Optic Nerve Atrophy

Charles Bonnet syndrome (CBS) can develop after trans-sphenoidal adenomectomy (TSA); however, the neural mechanisms remain unknown. Sensory deprivation and releasing phenomenon are both hypothetical explanations for this condition; however, there is no definite evidence that strongly supports either supposition. We report the first case of CBS after TSA without optic nerve atrophy. Postoperatively, the patient's vision seemed to be relatively well preserved, apart from the left-side hemianopsia in the right eye. Distinctive visual hallucinations only appeared when his eyes were closed, and these responded to quetiapine in a dose-dependent manner. Dose dependent change in colors and formation of hallucination was reported. Two weeks after quetiapine initiation, the patient's CBS was completely resolved. This unique case suggests that blocking sensory input from the periphery is more critical than neural damage of the bottom-up connection to the visual association cortex. In addition, quetiapine should be considered as a specific treatment for CBS.

Spheniodal mucocele causing bilateral optic neuropathy and ophthalmoplegia.

Sphenoid sinus mucocele comprises only 2% of all paranasal sinus mucoceles. In literature, there is a case report on sphenoidal mucocele causing bilateral optic neuropathy, with unilateral partial recovery and cranial nerve palsy, but we did not come across any literature with bilateral optic neuropathy and ophthalmoplegia together caused by spheno-ethmoidal mucocele. We present such a rare case of spheno-ethmoidal mucocele causing bilateral optic neuropathy and unilateral sixth nerve palsy who had postsurgery, unilateral good vision recovery, and complete resolution of sixth nerve palsy.

Trigemino-cardiac reflex: occurrence of asystole during trans-sphenoidal adenomectomy: a case report / 대한마취과학회지

The trigemino-cardiac reflex has been reported to occur during various craniofacial surgeries or procedures including manipulation of the trigeminal ganglion, tumor resection in the cerebellopontine angle, various facial reconstructions and trans-sphenoidal adenomectomy. Regarding risk factors during trans-sphenoidal adenomectomy, invasiveness closely related to the size of tumor and the degree of manipulation of cavernous sinus wall have been reported. We report the case of a 40-year-old female patient who had a relatively small-sized (< 10 mm) pituitary adenoma. Repetitive asystoles occurred during microscopic trans-sphenoidal operation of the wall of the cavernous sinus, which strongly suggests the importance of careful manipulation of the cavernous sinus wall. In addition to reporting this rare complication of trans-sphenoidal adenomectomy, we reviewed its clinical management by performing a literature search.

Análisis y seguimiento en 50 cirugías trans-esfenoidales de la región sellar / Analysis and monitoring in 50 consecutive transsphenoidal surgeries

El tratamiento de las lesiones de la región selar requiere un equipo multidisciplinario. La evaluación y seguimiento endocrinológico, neurooftalmológico y neuroradiológico, así como el desarrollo de la técnica quirúrgica, el diagnóstico histopatológico y a decisión sobre el tratamiento complementario apuntan a un manejo más integral de esta patología con el objetivo de lograr mejores resultados. Debido a la baja morbi-mortalidad del acceso transesfenoidal, la gran mayoría de las cirugías de la región selar se realizan con este acceso. Este estudio analiza retrospectivamente 50 cirugías transesfenoidales consecutivas realizadas por el autor, incluyendo la clínica, evaluación preoperatoria, algunos aspectos técnicos quirúrgicos, diagnóstico anátomopatológico, así como resultado y seguimiento postoperatorio en las diferentes patologías, con especial énfasis en aspectos como residuo tumoral, resultados endocrinológicos, neurooftalmológicos y complicaciones quirúrgicas. Los resultados fueron analizados estadísticamente y se compararon con los de la literatura.

The treatment of sellar region lesions requires a multidisciplinary approach. The endocrinologic, neuro-ophthalmologic and neuroradiologic evaluation and follow-up, as well as the development of the surgical technique, the histopathologic findings and the decision about complementary therapy aim to a more comprehensive treatment of these pathologies in order to achieve better outcome. Due to the low morbimortality risk of transsphenoidal approach, most of the surgeries of the sellar region are performed by way of this route. This study analyses retrospectively 50 consecutive transsphenoidal surgeries performed by the author, including clinical picture, preoperative evaluation, some issues regarding surgical technique, histopathological diagnosis, as well as results and follow-up in different diseases with special emphasis in residual tumor, endocrinologic and neuro-ophthalmologic outcome, and surgical complications. Results were statistically analyzed and compared to the literature.

Gamma Knife Radiosurgery for Growth Hormone-secreting Pituitary Adenoma following Trans-sphenoidal Approach

OBJECTIVE: The results of gamma knife radiosurgery(GKRS) for growth hormone(GH)-secreting pituitary adenoma are investigated to identify the role of adjuvant GKRS for remnant or recurrent tumor following transsphenoidal approach(TSA). METHODS: From March 1992 to December 2001, 20 patients treated by GKRS for GH-secreting pituitary adenoma following TSA were followed up more than 3 years and evaluated their symptomatic, hormonal and radiological changes after radiosurgery. RESULTS: There were 6 men and 14 women and the mean age was 40.2 years (range 24-58 years). The maximal dose was 32 to 60Gy (mean 46.2Gy) and the marginal dose was 12.8 to 36Gy (mean 25.5Gy). The mean follow-up time was 5.9 years (range 3-10years). Normalization of GH level (below 2ng/ml) was achieved in 10 of 20 patients (50.0%), and the normalization of IGF-I was in 8 of 15 patients (53.3%). On follow up MR imaging, the tumor control rate was 100% and the tumor volume reduction rate was 25~50% in 4 patients, 50~75% in 13 patients and 75~100% in 3 patients. CONCLUSION: In the treatment of GH-secreting pituitary adenoma, tumor control rate and improvement of clinical symptom show good outcome without major complication after adjuvant GKRS following TSA, though the rate of normalization of GH level is unsatisfactory. The optimal marginal dose for GH-secreting pituitary adenoma is more than 25Gy, and secondary GKRS can be considered in the failed cases to achieve effective hormonal normalization after the first adjuvant GKRS.

Sphenoid Sinus Mucocele(Case Report)

A case of mucocele of the sphenoid sinus having diplopia and headache is presented. This rare disorder is benign and curable by simple intranasal procedure. But it is often misdiagnosed as malignant or pituitary tumor, and unnecessary treatment such as radiotherapy or craniotomy has been performed. We removed it by sublabidal trans-septal trans-sphenoidal approach without difficulties and postoperative complications.

Stereotaxic Radiofrequency Hypophysectomy for Disseminated Breast and Prostate Cancer: Transseptal Transsphenoidal Approach

The authors performed three consecutive cases of stereotaxic radiofrequency hypophy-sectomies for patients with disseminated cancer from breast or prostate at Severance Hospital, Yonsei University. The procedures were essentially the same, in large part, as the technique first introduced by Zervas. The authors modified the-original technique to reduce the known risks of cerebrospinal fluid rhinorrhea and meningitis. Surgical details and clinical cases are presented.