Sellar Reconstruction and Rates of Delayed Cerebrospinal Fluid Leak after Endoscopic Pituitary Surgery.

Objectives Delayed cerebrospinal fluid (CSF) leaks are a complication in transsphenoidal surgery, potentially causing morbidity and longer hospital stays. Sella reconstruction can limit this complication, but is it necessary in all patients? Design Retrospective review. Setting Single-surgeon team (2005-2012) addresses this trend toward graded reconstruction. Participants A total of 264 consecutive patients with pituitary adenomas underwent endoscopic transsphenoidal resections. Sellar defects sizable to accommodate a fat graft were reconstructed. Main outcomes Delayed CSF leak and autograft harvesting. Results Overall, 235 (89%) had reconstruction with autograft (abdominal fat, septal bone/cartilage) and biological glue. Delayed CSF leak was 1.9%: 1.7%, and 3.4% for reconstructed and nonreconstructed sellar defects, respectively (p = 0.44). Complications included one reoperation for leak, two developed meningitis, and autograft harvesting resulted in abdominal hematoma in 0.9% and wound infection in 0.4%. Conclusion In our patients, delayed CSF leaks likely resulted from missed intraoperative CSF leaks or postoperative changes. Universal sellar reconstruction can preemptively treat missed leaks and provide a barrier for postoperative changes. When delayed CSF leaks occurred, sellar reconstruction often allowed for conservative treatment (i.e., lumbar drain) without repeat surgery. We found universal reconstruction provides a low risk of delayed CSF leak with minimal complications.

Primary glioblastoma of the trigeminal nerve root entry zone: case report.

Gliomas of the cranial nerve root entry zone are rare clinical entities. There have been 11 reported cases in the literature, including only 2 glioblastomas. The authors report the case of a 67-year-old man who presented with isolated facial numbness and was found to have a glioblastoma involving the trigeminal nerve root entry zone. After biopsy the patient completed treatment with conformal radiation and concomitant temozolomide, and at 23 weeks after surgery he demonstrated symptom progression despite the treatment described. This is the first reported case of a glioblastoma of the trigeminal nerve root entry zone.

Short-Term Quality-of-Life Changes after Endoscopic Pituitary Surgery Rated with SNOT-22.

Objective Little data exist on short-term quality-of-life (QOL) outcomes, specifically sinonasal measures, after endoscopic pituitary surgery. Design Prospective case series assessed sinonasal QOL before and after the transnasal endoscopic approach to the sella with resection of nasal cavity and sinus tissues. Setting/Participants/Main Outcome Measures A total of 39 adults scheduled to undergo resection for a pituitary mass preoperatively completed the Sinonasal Outcome Test-22 (SNOT-22). Rating various QOL issues, testing repeated postoperatively at 1 month by 37 patients and 3 months by 35 patients, was analyzed (paired Student t test). Results SNOT-22 scores (5-point scale; total: 110) averaged 23.4 preoperatively and 27.6 at 1 month but had significantly improved to 16.2 at 3 months (p = 0.03). Emotional well-being parameters (e.g., sadness, frustration, concentration, productivity, fatigue) significantly improved 3 months postoperatively (p < 0.05). Physiologic parameters (e.g., olfaction, obstruction, postnasal drainage) that had worsened at 1 month (< 0.05) then normalized at 3 months. Conclusion Total ratings for sinonasal QOL shows that SNOT scores were comparable between preoperative and 1-month testing but were improved significantly at 3 months. Individual questions showed marked improvement in emotional well-being and temporary physiologic changes after surgery. Our findings give surgeons information about what patients can expect immediately after transnasal endoscopic pituitary surgery.

Olfactory changes after endoscopic pituitary tumor resection.

OBJECTIVES: Given that the transnasal endoscopic approach to the sella involves resection of anatomical structures known to contain olfactory neuroepithelium, the effect of this approach on olfaction was evaluated. STUDY DESIGN: Case series with planned data collection. SETTING: Single tertiary care institution. SUBJECTS AND METHODS: Adults diagnosed with a pituitary mass and scheduled to undergo transnasal endoscopic resection underwent preoperative olfactory evaluation using the University of Pennsylvania Smell Identification Test (UPSIT). Repeat testing was performed at one and three months postoperatively. Paired Student t tests were used to compare preoperative and postoperative scores. RESULTS: A total of 57 consecutive patients were enrolled. Fifty patients (24 males, 26 females) completed olfactory evaluation at one month. Forty-five (23 males, 22 females) completed a three-month evaluation. The average UPSIT score (out of 40) was 31.8 preoperatively, 30.5 at one month, and 32.6 at three months. A significant difference was found between preoperative and one-month scores (P = 0.01) but not three-month scores (P = 0.08). CONCLUSION: A transient difference was found between preoperative and one month UPSIT scores. At three months, no clinically significant difference was found on repeat olfactory testing. Although the transnasal endoscopic approach to the sella removes structures known to contribute to olfactory function, it has no clinically significant effect on olfaction.

Anatomy of the optic canal: a computed tomography study of endoscopic nerve decompression.

OBJECTIVES: Endoscopic optic nerve decompression has variable success rates. Our goal was to further delineate the radiographic anatomy of the optic canal to determine whether the variable success can be explained on anatomic principles. METHODS: The optic canal dimensions and the degree of optic canal exposure to the sphenoid sinus were measured on sinus computed tomography images of 96 patients. RESULTS: A total of 191 optic canals were analyzed (111 female subjects and 80 male subjects). The average medial canal wall length was 1.48 cm (range, 0.7 to 2.3 cm). The length in male subjects was 1.61 cm (range, 1.1 to 2.3 cm), as compared to 1.39 cm (range, 0.7 to 2.0 cm) in female subjects (p < 0.001). Onodi cells and pneumatized anterior clinoid processes were present on 14 and 16 images, respectively. The average degree of exposure of the optic canal to the sphenoid sinus in optic canals without Onodi cells or clinoid pneumatization was 99.3 degrees, and in optic canals with both Onodi cells and clinoid pneumatization it was 117.7 degrees. The potential area of canal exposed was 0.66 cm2, or 28% of the total surface area. CONCLUSIONS: A wide variation in medial canal wall length and exposure of the optic canal to the sphenoid sinus exists on computed tomography images. Variation in medial canal wall length and optic canal exposure may limit the surface area of nerve available for endoscopic optic nerve decompression.