DISSERTATION ON

“A STUDY OF TRANSSPHENOIDAL ENDOSCOPIC

EXCISION OF PITUITARY ADENOMAS AND THEIR
OUTCOMES”

Dissertation submitted in partial fulfillment

of the regulations for the award of the degree of

M. S. DEGREE BRANCH-IV OTORHINOLARYNGOLOGY

of
MADURAI MEDICAL COLLEGE

DEPARTMENT OF OTORHINOLARYNGOLOGY,
MADURAI MEDICAL COLLEGE
DECEMBER 2024
 CERTIFICATE
This is to certify that this dissertation, “A STUDY OF TRANSPHENOIDAL ENDOSCOPIC
EXCISION OF PITUITARY ADENOMAS AND THEIR OUTCOMES,” submitted by
Dr. Thotchui Haorei, appearing for the M.S ENT Degree examination in December 2024-25,
is a bonafide record of work done by him under our guidance and supervision in partial
fulfillment of the regulations of the Tamilnadu Dr. M. G. R Medical University, Chennai. I am
forwarding this to Tamilnadu Dr. M. G. R Medical University, Chennai, Tamilnadu, India.

GUIDE
PROF DR. L. ARUL SUNDARESH KUMAR, MS ENT
Professor & Head of the Department
Department of ENT
Madurai Medical College and Government Rajaji Hospital
Madurai -625020

CO GUIDE
DR. B. MUTHUKUMAR, MS ENT
Assistant Professor
Department of ENT
Madurai Medical College and Government Rajaji Hospital
Madurai -625020

DEAN
Madurai Medical College and Government Rajaji Hospital
Madurai -625020

i
 DECLARATION
I solemnly declare that the dissertation entitled “A Study Of Transsphenoidal Endoscopic
Excision Of Pituitary Adenomas And Their Outcomes” was done by me at Madurai Medical
College & Government Rajaji Hospital, Madurai-20, from November 2022 to November 2023,
under the guidance and supervision of Prof. and Head of the Department, Dept. Of ENT, Prof.
DR. L. ARUL SUNDARESH KUMAR, MS ENT and DR. B. MUTHUKUMAR, MS ENT to
be submitted to The Tamil Nadu Dr. M. G. R Medical University towards the partial fulfillment
of requirements for the award of M. S. DEGREE in OTORHINOLARYNGOLOGY.

DR. THOTCHUI HAOREI

Post Graduate, M.S ENT,
Madurai Medical College & Government Rajaji Hospital - 625020
Place: Madurai
Date:

ii
 ACKNOWLEDGEMENT
I want to acknowledge and express my heartfelt gratitude to my guide, Prof. and Head of the
Dept., Dr. L. Arul Sundaresh Kumar, MS ENT, and my co-guide Dr. B. Muthukumar, MS
ENT, Department of Otorhinolaryngology. Their passion for teaching, dedication to patient
care, and active involvement in academics have been a great inspiration to me and my fellow
postgraduates. Their constant guidance and support have been invaluable to my academic and
professional development.

I am sincerely thankful to Prof. Dr. R. Veerapandian, Head of the Department, Neurosurgery,

for giving me the opportunity to work in the Department for my research. I also extend my
gratitude to Prof. Dr. J. Srisaravanan and Prof. Dr. G. Rajasekharan, whose unwavering support
and expert guidance played a pivotal role in completing my dissertation.

I also thank my seniors, colleagues, and juniors for their enduring support throughout the
project. I am deeply grateful to my patients, whose perseverance contributed to the success of
this endeavor. Additionally, I express my sincere appreciation to my family, friends and the
Almighty for granting me the strength and opportunity to see this project through to
completion.

iii
 CONTENTS
INTRODUCTION ..................................................................................................................... 1
AIM AND OBJECTIVES OF THE STUDY ............................................................................ 3
1.1. AIM: ............................................................................................................................ 3
1.2. OBJECTIVES: ............................................................................................................ 3
ANATOMY ............................................................................................................................... 4
LITERATURE REVIEW ........................................................................................................ 31
MATERIALS AND METHODS ............................................................................................. 57
OBSERVATIONS AND RESULTS ....................................................................................... 59
DISCUSSION .......................................................................................................................... 83
CONCLUSION ........................................................................................................................ 88
BIBLIOGRAPHY .................................................................................................................... 89
ANNEXURES ........................................................................................................................... 1
PROFORMA
INFORMATION SHEET
PATIENT CONSENT FORM
ABBREVIATIONS
ETHICAL COMMITTEE
DIGITAL RECEIPT
MASTER CHART

iv
 INTRODUCTION
The commonest lesion arising in the pituitary gland is a pituitary adenoma, which

accounts for 10-15% of all intracranial tumours originating from the pituitary's epithelial

cells. The clinical manifestations of pituitary adenoma may relate to the endocrine effects

of hormone deficiency, hormone excess, or a combination of both. Increasingly, with the

widespread use of sophisticated imaging techniques, lesions within the pituitary gland

may be identified before they become symptomatic, the so-called pituitary

incidentalomas. Depending on the size of the adenoma, it is classified as microadenoma

(<10mm) and macroadenoma (> 10mm). Pituitary adenomas are benign neoplasms that

do not typically metastasize and may be categorized into those that produce hormones

and those that fail to secrete gene products. These are referred to as functioning and

nonfunctioning. Functioning pituitary adenoma may arise from any one of the anterior

pituitary cell types, and the majority produce a single hormone. Nonfunctioning pituitary

adenomas are adenomas with no clinical evidence of hormone hypersecretion, usually

present as visual disturbances, headaches, and decreased pituitary hormones. Imaging

techniques have implications in surgery based on the tumor size, extent, and consistency

that determines the ease of resection, cure, and occurrence of complication. The transnasal

transsphenoidal endoscopic approach has recently been applied to a minimally invasive

to resect pituitary tumors.

Depending on the pneumatization of the sphenoid sinus, four general forms are described:

1) Conchal -with only a rudimentary sinus (2-3%)

2) Presellar-pneumatized as far as the anterior body wall of

the pituitary fossa (11%)

3) Sellar-pneumatization extends back beneath the

pituitary fossa (59%)

4) Mixed (27%) Figure 1: Types of sphenoid

sinus pneumatization.

Pituitary adenomas can cause symptoms such as headaches, visual disturbances,

galactorrhea, Cushing syndrome, infertility, and diabetes insipidus. Typically, a team of

specialists including neurologists, neurosurgeons, medical endocrinologists, ENT

surgeons, and ophthalmologists will evaluate the condition and plan the treatment

accordingly. They will assess the feasibility of the transnasal transsphenoidal endoscopic

approach before proceeding with surgery for these patients.

2
 AIM AND OBJECTIVES OF THE STUDY
1.1. AIM:

To study the transnasal transsphenoidal endoscopic excision of pituitary adenomas and

their outcomes.

1.2. OBJECTIVES:

1) To study the modes of presentation of pituitary adenoma.

2) To evaluate the tumours based on the radiological finding by computed tomography

(CT)/ magnetic resonance imaging (MRI) for further surgical management.

3) To study the surgical outcome, post-operative complications, and its management.

3
 ANATOMY

Figure 2: Pituitary gland.

The pituitary gland or hypophysis cerebri is an ovoid body measuring approx. 8mm in

the AP diameter by 12mm transversely by 4mm high. By the age of puberty it weights

approx. 100-150 mg. It doubles in size during pregnancy and usually remains larger in

females. The adenohypophysis constitutes two-thirds of the volume.

There are two major parts to the hypophysis:

1) Adenohypophysis: includes pars anterior, pars intermedia, and pars tuberalis

2) Neurohypophysis: includes pars posterior, infundibular stem, and median eminence.

Both parts include parts of the infundibulum and are preferred to the old terms anterior

and posterior lobes.

ADENOHYPOPHYSIS

This structure is highly vascular and consist of epithelial cells arranged in follicles and

cords between which lie thin-walled, vascular sinuses. This arrangement is supplied by a

delicate a skeleton of reticular tissue. Traditionally, cell types of adenophysis have been

divided up by their staining characteristics into chromophile and chromophobe cells.

4
 • Somatotrophs: (Acidophilic), the largest and most abundant chromophile cells,

these secrete the protein somatotrophin or growth hormone.

• Mammotroph: (Acidophilic) secrete the polypeptide hormone prolactin. They

become the dominant cells during pregnancy and lactation.

• Mammosomatotroph: (Acidophilic) secrete growth hormone and prolactin

simultaneously.

• Corticotroph: (Basophilic) produce the precursor molecule pro-

opiomelanocorticotropin which is broken down into adenocorticotropin, beta-

lipotropin and beta-endorpin.

• Thyrotrophs: (Basophilic) secrete thyroid stimulating hormone.

• Gonadotroph: (Basophilic) secrete follicle stimulating hormone and luteinizing

hormone.

• Chromophobe cells: they include stem cells and degranulated secretory cells.

• Folliculostellate cells: they are supporting cells of the adenohypophysis with

growth factor and cytokine activity.

• Pars tuberalis: contains a large number of blood vessels as well as secretory cells.

NEUROHYPOPHYSIS:

Axons with their cell bodies in the supraoptic and paraventricular nuclei of the

hypothalamus run to the neurohypophysis. The two hormones secreted in this way are:

• Anti-diuretic hormone or Vasopressin

• Oxytocin.

5
EMBRYOLOGY:

Figure 3: Embryological development of pituitary gland.

The adenohypophysis is derived from the placoidal ectoderm of the stomadeum roof. The

neurohypophysis is derived from an evagination of the floor of the forebrain and the third

ventricle. The saccular depression in the roof of the stomadeum immediately in front of

the oropharyngeal membrane. This saccular depression evaginates to form the pouch of

Rathke. The pouch of Rathke develops into adenohypophysis. The anterior part becomes

the pars anterior and the posterior part, in contact with the forebrain, becomes pars

intermedia. The forebrain section in close contact with the pars intermedia becomes the

neurohypophysis. Remnants of the Rathke pouch may persist below the sphenoid in the

roof of the nasopharynx, forming the pharyngeal pituitary. The clivus and the dorsum

sellae of the sphenoid bone are formed from mesochymal condensation surrounding the

hypophysis. The cavernous sinus is derived from the primary head vein.

6
MORPHOGENESIS

The glandular epithelium is differentiated from Rathke’s pouch and is characteristic of

other endocrine organs. The exocrine ductless tissue is formed by the infundibulum. The

anterior end of notochord situated caudal to stomodeum induces glandular and neural

primordial leading to development of hypophysis.

In 3rd week of intrauterine life3, the ventral diverticulum in the floor of the third ventricle

developed from the infundibulum, leading to the infundibular process by extension from

the median eminence known as the infundibular stem. Dorsally an ectodermal placode

appears in the stomodeum roof and forms Rathke’s pouch by invagination

simultaneously.

By 2nd month of intrauterine life, intergration of Rathke’s pouch and infundibulum

occurs by flattening of former with anterior and laterl surface of latter. There occurs pass

through of chondrification centers of developing presphenoid and basisphenoid skull

bones due to connection between Rathke‟s pouch and oral cavity. By 6th week

,expansion of sphenoidal mesenchyme leads to regression of this connection.

Remnants of Rathke’s pouch during its course if persists in oropharyngeal roof or in

sphenoid bone presents as pharyngeal hypophysis or as basipharyngeal canal. The

anterior lobe of pituitary (adenohypophysis) is formed by the cellular proliferation of

Rathke’s pouch’s anterior wall-pars distalis. The pars intermedia is of less active walls of

posterior Rathke’s pouch1{cells do not proliferate extensively but differentiated}, upward

growth of anterior wall forms pars tuberalis. The Rathke’s pouch, which is incompletely

obliterated, leads to remnant form Rathke’s cleft/pituitary fissure. The differentiation of

7
neural ectoderm into pars nervosa, infundibular stem, and median eminence leads to the

development of neurohypophysis

Infundibular stem is surrounded by pars tuberalis together comprises pituitary stalk. The

neurohypophysis consists of neuroglial cells (pitucytes) as well as nerve fibres and

terminal cells originating from hypothalamic nuclei. Apart from secretion and transport

of hormones from neurohypophysis, pituicytes have phagocytic activity.

HISTOGENESIS

The third and fourth month of gestation anterior lobe cells arranged cords around blood

sinuses with surrounding mesenchyme inducing glandular organisation. By first trimester

the portal blood vessels are fully established. differentiation of anterior lobe cells

characterized affinity of cytoplasm into acidophilic basophilic, and

chromophobes.Basophilic cells concentrated in pars medialis whereas acidophilic cells

are concentrated inpars lateralis.the early detected hormones are corticotrophs

betaendorphin and leutinising hormone and follicular stimulating hormone.Trh developed

in early second trimester .during second half of pregnancy growth hormone and -prolactin

are synthesised.In late fetal life neurosecretory activity of posterior lobe begins

8
ANATOMY OF SPHENOID AND ANTERIOR SELLA WALL:

Figure 4: Anatomy of Sphenoid with the sellar wall.

The anatomical considerations for the endoscopic pituitary surgeon are:

• The degree of pneumatization of the sphenoid and the localization of the anterior

sella wall

• The position of the intra-sphenoid sinus septae

• The positioning of the carotid arteries and optic nerve in the posterior sphenoid

wall.

The degree of pneumatization of sphenoid sinus is divided into sellar, pre-sellar, conchal,

mixed. In sellar type the sphenoid is well pneumatized and the floor of the pituitary fossa

performs an easily identifiable bulge in the posterosuperior aspect of the sphenoid sinus.

This arrangement is found in 80% of sinuses.The posterior wall of the sphenoid sinus is

9
in the same plane as the midpoint of the pituitary fossa or more posteriorly placed. In 2%

of cases there is no pneumatization of the sphenoid.

INTRA-SPHENOID SINUS SEPTAE:

The arrangement of the septae is highly variable. The commoner arrangement are of a

single septum (48%) or two septae(48%) rather than multiple septations. The septae

maybe complete or incomplete where they extend from the anterior to the posterior wall

of the septum. Anteriorly the septum is usually inserted in the midline, but its posterior

attachment is variable. Midline posterior attachment occur in only 14% of the individuals

and more commonly the arrangement is that the posterior attachment is laterally placed

close to the paraclival carotid eminence. In 87% of the cases atleast one septum will be

inserted posteriorly close to the carotid. Transverse septations as well as vertical

septations are also encountered. Where there are horizontal sphenoid septae, this is due

to posterior ethmoids pneumatizing over the top of sphenoid sinuses.

CAROTID ARTERIES AND OPTIC NERVES:

SELLAR ANATOMY

The sphenoid bone is the entry for the skull base that is located in the center of the skull

base. The recent endoscopic approach to skull base is to access to the middle skull base.

The bony constitute of sella turcica forms the limitation of the pituitary fossa anteriorly,

posteriorly and inferiorly. The average bone thickness is 0.4mm and the average distance

from fossa is 14-17cm. The anterior boundary forms tuberculum sella, whereas the

posterior boundary forms dorsum sella. A minimal groove lies at the optic foramen, which

10
forms the chiasmatic sulcus. The seller tuberculum lies posterior and the sphenoidal

planum anterior to the chiasmatic sulcus.

Rounded knob like structures formed by supralateral margins of dorsum sella called

posterior clinoid process. The middle clinoid process are lateral to the tuberculum sella.

Anterior clinoid process located in the medial wing of lesser wing sphenoid.

The dorsum sella is continuous as clivus the superior portion of which formed by bone

of sphenoid and inferior portion is formed by occiput bone. Along lateral surface of the

body of sphenoid extends the carotid sulcus. Hypophyseal floor is formed by roof of

sphenoid sinus partly/completely.

Sphenoid sinus is subject to considerable variation in size, shape and to degree of

pneumatization. Adult sphenoidal sinuses based with pneumatization are-

conchal,presellar, sellar type. Conchal type- a solid block of bone without air cavity below

sella. Presellar type- penetration of air cavity does not occur beyond vertical plane parallel

to anterior sellar wall. Sellar type- air cavity enters extend into body of sphenoid below

the sella as posteriorly as the clinus. The septa /bony trabeculae within the sphenoid sinus

vary in size, shape, thickness, location, completeness and relation to the sellar flow. Only

in 25% of the cases inter sinus septum is attached to the midpoint of anterior sella and

may be absent altogether. The posterior attachment of inter sinus septum to serpiginous

prominence produced by carotid artery into the sinus wall below the floor and along the

anterior margin of the sella. Usually optic nerve protrude into supralateral portion of the

sella and inferolateral part of the second part of the trigeminal nerve protrusion.

At birth the shallow depression at sella dorsum ossification not occurred. By approx.

fopur years of age sella outline becomes more rounded. Diaphragma sella forms the

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incomplete roof of sella turcica covering the pituitary gland except for central opening

for transmitting pituitary stalk. The shape of diaphragm sella is more of rectangular and

has convexity or concavity.

The anterior lobe of pituitary from overlying optic chiasma is separated by diaphragm

sella. The margins of diaphragm are attached to the tuberculum sella, anterior clinoid

process and dorsum sella superior aspect. The lateral wall of pituitary fossa is by lateral

continuation of diaphragm with dural folds. The variable size in central aperture of

diaphragm ranging from a small foramen to a large hole surrounded by a tenacious

membrane of tissues. A deficiency in diaphragm sella is preconditioned to form empty

sella. Though this central opening in diaphragm sella an outpouching arachnoid protrudes

in 50% of cases indicates important source of post operative cerebrospinal leak.

PITUITARY GLAND

It a pea shaped gland situated in fibro osseous compartment within the hypophyseal fossa

at the centre of the skull base. It weighs 100mg averagely at birth. The Adult size is 10mm

in length, 10-15mm width and 5mm in height. Female gland is 20% heavier than male

gland. The weight of the gland increases by 12-100% during pregnancy. Accurate size

can be measured with MRI. The volume of pituitary gland decreases with ageing. The

lower part of the pituitary stalk is wrapped by anterior lobe to form pars tuberalis.

Compared to anterior lobe posterior lobe is more adherent to sella wall.

In most patients the width of the gland is equal or more of the length/height. The shape

of the floor is confirmed by inferior surface of the gland even the anterior and superior

marginary in shape as the wall are composed of soft tissue rather than bone. The gland

tends to be concave superiorly in the area around the stalk as there is a large opening

12
around the diaphragm. As the result of compression of gland laterally and posteriorly by

the carotid artery. The tendency of pars tuberalis to be retained with the posterior lobe as

the anterior lobe is separated from the posterior lobe . during the separation of the anterior

and posterior lobe the intermediate lobe cyst are frequently encountered.

PARASELLAR/SUPRASELLAR ANATOMY

The lateral wall of the hypophyseal fossa formed by folds of duramater contains

cavernous sinuses consisting serially arranged compartment of venous channels separated

by fibrous trabeculae. The communications between two cavernous sinuses leads to

intercavernous connections named on the basis of relationship to pituitary gland ie,

anterior intercavernous sinus runs anterior to diaphragma sella and posterior

intercavernous sinus behind the pituitary stalk. The anterior sinus is usually large than the

posterior sinus but either or both may be absent if connections coexist forms circular

sinuses. The lateral wall of the cavernous sinus, the occulomotor nerve, trochlear nerve

and the first two division of trigeminal nerve are embedded lying between the dura and

the endothelial lining but the abducens nerve is present with the sinus. A small portion of

the internal carotid artery encircle with the symphathetic nerve trunk is enveloped by

cavernous sinus. The forward extension cavernous segment of the internal carotid artery

is adjacent to the supra lateral surface of the body of sphenoid bone with groove known

as carotid sulcus. The ICA courses superiorly medial to the anterior clinoid process at the

anterior end of carotid sulcus and pierces the dura and enter the subarachnoid space. ICA

medially limit approx. 5mm away from the midline whereas lateral limit vary 13-20mm

from midline. The supra sellar region over the hypophysis is hypothalamus and visual

pathways.

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 Depending upon the variations in development of sphenoid bone just anterior to the

hypophyseal fossa producing inconsistency in the relation between pituitary gland, stalk,

diaphragma sella, sulcus chiasmaticus. The variation are:

1) The body of sphenoid develops so that sulcus chiasmaticus is more inferior than

usual known as prefixed chiasma present in 10% of the cases.

2) The intracranial course of optic nerve is slightly larger than the preceding pattern.

Therefore the entire optic chiasma rest above the anterior part of diaphragma sella

leading to most vulnerable of optic chiasma to supra sellar extension of pituitary

tumour in 12% of cases.

3) Optic chiasma most posteriorly placed than the previous arrangement in 75% of

the cases.

4) Optic chiasma located on and behind dorsal sella leads to vulnerability of the

medial aspect of optic nerve when suprasellar extension of intrasellar tumour.

NERVE SUPPLY

The anterior pituitary has no direct nerve supply other than autonomic nerves. The

posterior nerve is almost exclusively by hypothalamic nerve fibres. Hypothalamic

projections release hormones and trophic factors by neurosecretion into the median

eminence and portal system. There are two principal tracts; the hypothalamo-hypophyseal

tract arises in the magnocellular neurons of the supraoptic and paraventricular nuclei and

releases vasopressin and oxytocin into the posterior pituitary, the parvocellular neurons

of the tubero-infundibular tract originate in multiple hypothalamic nuclei and project into

the median eminence.

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BLOOD SUPPLY

The adenohypophysis and hypothalamus share a complex portal blood supply carrying

trophic and inhibitory hormones from the hypothalamus, thus regulating systemic release

of anterior pituitary hormones. The anterior pituitary has no direct blood supply, branches

of the superior, meddle and inferior hypophyseal artery supply the median eminence and

posterior pituitary. The superior hypophyseal arteries branch into an internal and external

plexus. The internal plexus forms glomeruloid structures known as gomitoli. Gomitoli

regulate the flow of regulatory hormones in the pituitary paracrine biological network and

are the presumed origin of sellar glomangiomas. The inferior artery supply the pituitary

capsule, the neural lobe and pituitary stalk. The venous drainage of the pituitary gland is

to the inferior petrosal sinuses via the cavernous sinus. The capacity of the venous

drainage is exceeded by the volume of blood entering the gland , thus forming the

reservoir. Reversal of the blood flow here results in the secretory products from the

adenohypophysis entering the neurohypophysis and median eminence. The vascular

anatomy is important in the pathophysiology of apoplexy.

PHYSIOLOGY OF PITUITARY

Pituitary gland consist of two principle lobes anterior lobe ,posterior lobe and

intermediate lobe situated between the anterior and posterior lobe. Anterior lobe secretes

growth hormone (GH), thyroid stimulating hormone( TSH), adeno cortico trophic

hormone(ACTH), gonadotrophic hormone(GnRH), follicular stimulating hormone

(FSH), leutinizing hormone(LH), prolactin.

Secretion of anterior pituitary hormone is governed by hormones from the median

eminence of hypothalamus. Corticotrophin, prolactin and growth hormone are simple

15
polypeptides whereas leutinizing hormone, follicle stimulating hormone, thyroid

stimulating hormones are glycoproteins.

The glycoproteins are made up of two subunits (hetero dimer namely alpha and beta).

Alpha subunits hormones are products of chromosome 6 of a single gene. Beta subunit

varying in structure produced by different genes. Secretion of alpha subunits only

describe with the context of non functioning pituitary adenoma.

Serum levels of pituitary hormones along with alpha subunit can be measured by radio

immunoassay. Growth hormone- the somatotroph of anterior pituitary secretes peptide

hormones known as growth hormones. Growth hormone releasing hormones (GHRH)

stimulates secretion of growth hormones. Somatomedin exerts range of wide metabolic

actions. Hypoglycemia increase plasma levels of aminoacids, decrease plasma free fatty

acids, inhibit uptake of glucose by most of tissues. Glucose is conserved for brain use by

anti insulin action, promotes lipolysis- non carbohydrate substrate for ATP generation.

Synthesis of protein is promoted by GH and is crucially needed between the age of three

years and puberty for normal skeletal growth. Synthesise of IGF and its secretion

stimulated by growth hormone. The cartilage cells derived and deposited at epiphysis(

growth plate) is encouraged and enhanced by IGF.

The pituitary gland normally secretes GH with a molecular weight of 22000. Cortico

trophin hormone secreted by anterior pituitary corticotroph. The action of corticotrophin

for the basal secretion of glucocorticoid and aldosterone as well as hormone produced

by various stresses acts on the adrenal gland. Rapid atrophy of adrenal cortex occurs after

hypophysectomy. It is a polypeptide containing 39 amino acids with its half life in

16
circulation approx. 10 minutes participating in rapidly adjustment of circulatory levels of

glucocorticoids is due to half life property.

ACTH regulates the secretion of glucocorticoids steroid hormones and response to

stress. Pituitary glycoprotein hormones- TSH, FSH,LH.TSH regulates the secretions of

thyroxine (T4) and tri iodo thyronine. These secretions are regulated by hypothalamic

TRH. A triangular peptide in medial part of paraventricular nucleus.

TSH contains 211 amino acids and biological half life of 60 minutes. TSH secretion is

pulsatile and peaks out during midnight. ATSH acts on cell receptors and activates

adenylyl cyclise through a GTP binding protein. TRH is increased during exposure to

cold temperature. By feedback inhibition T3 and T4 levels are blocked by TSH

FSH and LH regulates the function of gonads. The secretion is influenced by

hypothalamic gonadotrophic releasing hormones (GnRH) which is a decapeptide. In

female the FSH helps in preparation for ovulation and secretion of oestrogen by growing

follicles. LH triggers ovulation and production of progesterone by corpus luteum. In male

,FSH is needed for spermatogenesis while LH produce testosterone by Leydig cells. The

half life of FSH is 170 minutes and that of LH is 60 minutes.

Secretion of GnRH is pulsatile for purpose of reproduction and endocrine function.

Inhibin is synthesized in gonads of both sexes is a polypeptide that inhibit FSH.

Prolactin contains 198 amino acids residues. Half life is 20 minutes similar to growth

hormone and the receptor also resembles growth hormones and undergoes dimerization

before activating several intra cellular enzymes cascades. PRL secretion is usually

inhibited by hypothalamic prolactin inhibiting hormone or prolactin inhibiting factor

17
called dopamine. Hormonal release is generated in response to sucking which inhibits the

hypothalamic dopamine release in lactating women. Prolactin inhibit the action of

gonatrophin on ovary that prevents ovulation during lactation or those with prolactin

secreting tumour. Excessive secretion of prolactin in male leads to impotence.

Physiology of intermediate lobe – about 3.5% of glandular mass of pituitary cells of

pars media in human fetus but less than 1% in adults. The pars intermedia synthesise

POMC, a large protein precursor. The principal products of POMC hydrolysed to form

CLIP, gamma lipoprotein, beta endorphin and melanotrophins.

The intermediate lobe form two melanotrophins- alpha MSH and beta MSH where beta

MSH controls migration of pigment molecules. Melanin synthesise is due to MSH

molecule binded to melanotrophin 1 receptor on melanocytes.

Physiology of posterior pituitary – oxytocin and vasopressin are the hormones of

posterior lobe. The later also called as anti diuretic hormone(ADH) as one its principal

physiological effects is retention of water by kidneys. In response to electrical activity at

the axon endings posterior lobe hormones are released into general circulation. Both these

hormones contains nonapeptides with the disulfide ring at one end. Synthesise of this

hormone occurs in the cell bodies of the magnocellular neurons of supraoptic and

paraventricular nuclei of hypothalamus. Supra optic fibres mostly ends in posterior lobe

itself whereas paraventricular fibres some end in median eminence as well. Released of

stored hormones is triggered by calcium dependent exocytosis in response to action

potential.

Oxytocin -action of oxytocin occurs through G-protein coupled receptors of cell surface,

triggering of which increases intracellular calcium in response to activation. Oxytocin

18
causes contraction of myoepithelial cells lining the breast ducts .Tactile stimulation of

nipples leads to flow of milk from alveoli of breast. Contraction of uterine smooth

muscles during delivery leads to fetal descent and enhance labour and in non pregnant

uterus acts by facilitation of sperm passage in to fallopian canal. In man oxytocin

increases at the time of ejaculation that propels sperm towards urethra by contraction of

vas deferens smooth muscle.

Vasopressin (ADH- anti diuretic hormone) acts through cell surface receptors namely

serpentine, transmembrane and G protein coupled receptors leads to formation of second

messenger and exerts many physiological effects on body. Vasopressin’s half life is 18

minutes.

Acting on collecting ducts; permeability of collecting duct is increased by aquaporin

water channels translocation from endosomal compartment to luminal side enables entry

of water to the hypertonic interstitium of renal pyramid. This leads to decrease in urine

volume and increase in concentration of urine. Condition that increase ADH are decreased

blood volume, increase plasma osmotic pressure, increased angiotensin II levels, pain,

emotion and exercise. ADH secretion is inhibited by alcohol. Vasopressin is potent

vascular smooth muscle constrictor and also acts by paracrine action on anterior pituitary

and releases corticotrophin hormones.

DEVELOPMENT OF PITUITARY GLAND

From the developing embryo, the pituitary originates with two parts: 1) dorsal evagination

of stomodeum known as Rathke’s pouch that is anteriorly immediate to buccopharyngeal

membrane with a ventral extension caudally to optic chiasma of diencephalon known as

19
infundibulum, both are derivatives of ectoderm. 2) The pouch of Sessel is another dorsal

evagination of the stomodeum arising posteriorly from the buccopharyngeal membrane.1,2

Sellar anatomy- the sphenoid bone is the entry for skull base that is located in the centre

of skull base.recently the endoscopic endonasal approach to skullbase iss accesss to the

middle of the skull base.the bony constituents of sella turcica forms the limitation of the

pituitary fossa anteriorly posteriorly and inferiorly .the average bone thickness is 0.4mm

.the average distance from fossa is 14 to 17 cm.anterior boundary of pituitary fossa forms

tuberculum sella whereas posterior boundary forms dorsum sella. A minimal groove lie

at optic foramen which forms chiasmatic sulcus. The sellar tuberculum lies posterior and

sphenoidale planum anterior to the chiasmatic sulcus.

Rounded knob like structures formed by supralateral margins of dorsum sella called as

posterior clenoid process.The middle clenoid process are lateral to the tuberculum sella

.Anterior clenoid process located in the medial wing of lesser wing sphenoid.

The dorsum sella is continuous as clivus the superior portion of which is formed by bone

of sphenoid and inferior portion is formed by bone of occiput.Along lateral surface of the

body of sphenoid extends the carotid sulcus.Hypophyseal floor is formed by roof of

sphenoid sinus partly/completely.

Sphenoid sinus is subject to considerable variation in size shape and to degree of

pneumatisation. Adult sphenoidal sinuses based with pneumatisation are –conchale

,presellar and sellar type.Conchale type - a solid block of bone without air cavity area

below the sella.Presella type -penetration air cavity does not occur beyond the vertical

plane parallel to the anterior cellar wall. Sellar type-air cavity enters and extends into a

body of the sphenoid below the sella as posteriorly as the clivus. The septa/bony

20
trabeculae within the sphenoid sinus vary in size, shape, thickness location, and

completeness, and relation to the sellar flow. Only in 20% of cases inter sinus septum is

attatched to midpoint of anterior sella and may be absent altogether.The posterior

attatchment of inter sinus septum to serpeginous prominence produced by carotid artery

into the sinus wall below the floor and along the anterior margin of the sella.Usually optic

canal protrude into supra lateral portion of the sella and infrolateral part of the second

division of trigerminal nerve protrudes.

High variability of Sella contour –round/ oval /profile with flattened although .At birth

shallow depression at sella dorsum ossification not occurred. By approximately four years

of age sella outline appears more rounded .Diaphragma sella forms the incomplete roof

of sella turcica covering the pituitary gland except a central opening for transmitting

pituitary stalk.The shape of diaphragm sella is more of rectangular and has convexity or

concavity.

The anterior lobe of pituitary from overlying optic chiasma is separated by diaphragm

sella.The margins of diaphragm are attatched to the tuberculum sella , anterior clinoid

process and dorsum sella superior aspect.The lateral wall of pituitsry fossa is by lateral

continuation of diaphragm with dural folds.The variable size in central aperture of

diaphragm ranging from a small foramen to a large hole surrounded by a tenacious

membrane of tissues. A deficiency in diaphragm sella is preconditioned to form an empty

sella. Though this central opening in the diaphragm sella an outpouching arachnoid

protrudes in 50% of cases, it indicates the important source of post-operative

cerebrospinal leak.

21
PITUITARY GLAND

It is a pea-shaped gland in the fibro-osseous compartment within the hypophyseal fossa

at the center of the skull base. It weighs 100mg on average at birth. The Adult size is

10mm long, 10-15mm wide, and 5mm in height. The female gland is 20% heavier than

the male gland. The weight of the gland increases by 12-100% during pregnancy.

Accurate size can be measured with MRI. The volume of the pituitary gland decreases

with aging. The anterior lobe wraps the lower part of the pituitary stalk to form pars

tuberalis. The posterior lobe is more adherent to the sella wall than the anterior lobe.

In most patients, the width of the gland is equal to or more than the length/height. The

shape of the floor is confirmed by the inferior surface of the gland, even the anterior and

superior marginal in shape, as the walls are composed of soft tissue rather than bone. The

gland tends to be concave superiorly in the area around the stalk as there is a large opening

around the diaphragm, which results from the gland laterally and posteriorly compression

by the carotid artery. The pars tuberalis tend to be retained with the posterior lobe as the

anterior lobe is separated from the posterior lobe. The intermediate lobe cyst is frequently

encountered during the separation of the anterior and posterior lobes.

PARASELLAR/SUPRASELLAR ANATOMY

The hypophyseal fossa's lateral wall formed by duramater folds contains cavernous

sinuses consisting of serially arranged compartments of venous channels separated by

fibrous trabeculae. The communications between two cavernous sinuses lead to

intercavernous connections named based on the relationship to the pituitary gland, i.e.,

the anterior intercavernous sinus runs anterior to the diaphragma sella and the posterior

intercavernous sinus behind the pituitary stalk. The anterior sinus is usually more

22
significant than the posterior sinus, but either or both may be absent if connections coexist

and form circular sinuses. The lateral wall of the cavernous sinus, the oculomotor nerve,

the trochlear nerve, and the first two trigeminal nerve divisions are embedded between

the dura and the endothelial lining. Still, the abducens nerve is present in the sinus. A

small portion of the internal carotid artery encircled by the sympathetic nerve trunk is

enveloped by a cavernous sinus. The forward extension cavernous segment of the internal

carotid artery is adjacent to the supra lateral surface of the body of the sphenoid bone with

a groove known as the carotid sulcus. The ICA courses are superiorly medial to the

anterior clinoid process at the anterior end of the carotid sulcus, pierces the dura, and

enter the subarachnoid space. ICA medially limits approx. 5mm away from the midline,

whereas the lateral limit varies 13-20mm from the midline. The suprasellar region over

the hypophysis is the hypothalamus and visual pathways.

Depending upon the variations in the development of sphenoid bone just anterior to the

hypophyseal fossa produce inconsistency in the relation between the pituitary gland,

stalk, diaphragma sella, and sulcus chiasmaticus. The variations are:

1) The sphenoid body develops so that sulcus chiasmaticus is inferior to usual, known

as prefixed chiasma, in 10% of cases.

2) The intracranial course of the optic nerve is slightly larger than the preceding pattern.

Therefore, the entire optic chiasma rests above the anterior part of the diaphragma

sella, leading to the most vulnerability of optic chiasma to the suprasellar extension

of a pituitary tumor in 12% of cases.

3) Optic chiasma is more posteriorly placed than the previous arrangement in 75% of

the cases.

23
4) Optic chiasma located on and behind dorsal sella leads to vulnerability of the medial

aspect of optic nerve when suprasellar extension of intrasellar tumour.

NERVE SUPPLY

The anterior pituitary has no direct nerve supply other than autonomic nerves. The

posterior nerve is almost exclusively made of hypothalamic nerve fibers. Hypothalamic

projections release hormones and trophic factors by neurosecretion into the median

eminence and portal system. There are two principal tracts; the hypothalamo-hypophyseal

tract arises in the magnocellular neurons of the supraoptic and paraventricular nuclei and

releases vasopressin and oxytocin into the posterior pituitary, the parvocellular neurons

of the tubero-infundibular tract originate in multiple hypothalamic nuclei and project into

the median eminence.

CIRCULATORY SUPPLY

The adenohypophysis and hypothalamus share a complex portal blood supply carrying

trophic and inhibitory hormones from the hypothalamus, thus regulating the systemic

release of anterior pituitary hormones. The anterior pituitary has no direct blood supply;

branches of the superior, middle, and inferior hypophyseal artery supply the median

eminence and posterior pituitary. The superior hypophyseal arteries branch into an

internal and external plexus. The internal plexus forms glomeruloid structures known as

gomitoli. Gomitoli regulates the flow of regulatory hormones in the pituitary paracrine

biological network and is the presumed origin of sellar glomangiomas. The inferior artery

supplies the pituitary capsule, the neural lobe, and the pituitary stalk. The venous drainage

of the pituitary gland is to the inferior petrosal sinuses via the cavernous sinus. The

capacity of the venous drainage is exceeded by the volume of blood entering the gland,

24
thus forming the reservoir. Reversal of the blood flow here results in the secretory

products from the adenohypophysis entering the neurohypophysis and median eminence.

The vascular anatomy is essential in the pathophysiology of apoplexy.

Figure 5: Sellar and parasellar region (endoscopic anatomy)

25
PHYSIOLOGY OF PITUITARY

Figure 6: Physiology of pituitary gland.

The pituitary gland consists of two principal lobes, the anterior lobe, the posterior lobe,

and the intermediate lobe, between the anterior and posterior lobes. The anterior lobe

secretes growth hormone (GH), thyroid stimulating hormone (TSH), adeno cortical

trophic hormone (ACTH), gonadotrophic hormone (GnRH), follicular stimulating

hormone (FSH), luteinizing hormone (LH), and prolactin.

Secretion of anterior pituitary hormone is governed by hormones from the median

eminence of the hypothalamus. Corticotrophin, prolactin, and growth hormone are

26
simple polypeptides, whereas luteinizing, follicle-stimulating, and thyroid-stimulating

hormones are glycoproteins.

The glycoproteins comprise two subunits (hetero dimer, namely alpha and beta). Alpha

subunit hormones are products of chromosome 6 of a single gene—beta subunit varying

in structure produced by different genes. Secretion of alpha subunits is only described in

the context of nonfunctioning pituitary adenoma.

Serum levels of pituitary hormones, along with the alpha subunit, can be measured by

radioimmunoassay. Growth hormone- the somatotroph of the anterior pituitary secretes

peptide hormones known as growth hormones. Growth hormone-releasing hormones

(GHRH) stimulate the secretion of growth hormones. Somatomedin exerts a range of

broad metabolic actions. Hypoglycemia increases plasma levels of amino acids, decreases

plasma-free fatty acids, and inhibits the uptake of glucose by most tissues. Glucose is

conserved for brain use by anti-insulin action and promotes lipolysis - a noncarbohydrate

substrate for ATP generation.

GH promotes protein synthesis and is crucially needed for normal skeletal growth

between three years and puberty. Growth hormones stimulate the synthesis and secretion

of IGF. The cartilage cells derived and deposited at the epiphysis( growth plate) are

encouraged and enhanced by IGF.

The pituitary gland normally secretes GH with a molecular weight of 22000.

Cortico trophin hormone is secreted by the anterior pituitary corticotroph. The action of

corticotrophin for the basal secretion of glucocorticoid and aldosterone, as well as

hormones produced by various stresses, acts on the adrenal gland. Rapid atrophy of the

adrenal cortex occurs after hypophysectomy. It is a polypeptide containing 39 amino

27
acids, and its half-life in circulation is approximately 10 minutes, rapidly adjusting

circulatory levels of glucocorticoids due to half-life property.

ACTH regulates the secretion of glucocorticoid steroid hormones and stress response—

pituitary glycoprotein hormones- TSH, FSH, LH.TSH regulates the secretions of

thyroxine (T4) and triiodothyronine. Hypothalamic TRH regulates these secretions—a

triangular peptide in the medial part of the paraventricular nucleus.

TSH contains 211 amino acids and a biological half-life of 60 minutes. TSH secretion

is pulsatile and peaks out at midnight. ATSH acts on cell receptors, activating adenylyl

cyclase through a GTP-binding protein. TRH is increased during exposure to cold

temperatures. By feedback inhibition, T3 and T4 levels are blocked by TSH.

FSH and LH regulate the function of gonads. The secretion is influenced by hypothalamic

gonadotrophic releasing hormones (GnRH), which are decapeptides. In females, the FSH

helps in preparation for ovulation and secretion of estrogen by growing follicles. LH

triggers ovulation and the production of progesterone by the corpus luteum. FSH is

needed for male spermatogenesis, while LH produces testosterone by Leydig cells. The

half-life of FSH is 170 minutes, and LH's is 60 minutes.

Secretion of GnRH is pulsatile for reproduction and endocrine function. Inhibin is

synthesized in the gonads of both sexes and is a polypeptide that inhibits FSH.

Prolactin contains 198 amino acid residues. Half-life is 20 minutes, similar to growth

hormone, and the receptor also resembles growth hormones and undergoes dimerization

before activating several intracellular enzyme cascades. PRL secretion is usually

inhibited by hypothalamic prolactin-inhibiting hormone or prolactin-inhibiting factor

28
called dopamine. Hormonal release is generated in response to sucking, which inhibits

the hypothalamic dopamine release in lactating women. Prolactin inhibits the action of

gonadotrophin on the ovary that prevents ovulation during lactation or with prolactin-

secreting tumours—excessive secretion of prolactin in males leads to impotence.

Physiology of intermediate lobe – about 3.5% of the glandular mass of pituitary cells

of pars media in human fetuses but less than 1% in adults. The pars intermedia synthesize

POMC, a large protein precursor. The principal products of POMC are hydrolyzed to

form CLIP, gamma lipoprotein, beta endorphin, and melanotrophins.

The intermediate lobe forms two melanotrophins- alpha MSH and beta MSH, where beta

MSH controls the migration of pigment molecules. Melanin synthesis is due to the MSH

molecule's binding to the melanotrophin one receptor on melanocytes.

Physiology of posterior pituitary – oxytocin and vasopressin are the hormones of the

posterior lobe. The latter is also called antidiuretic hormone (ADH), as one of its principal

physiological effects is water retention by the kidneys. In response to electrical activity

at the axon endings, posterior lobe hormones are released into general circulation. Both

these hormones contain nonapeptides with the disulfide ring at one end. Synthesise of this

hormone occurs in the cell bodies of the magnocellular neurons of the supraoptic and

paraventricular nuclei of the hypothalamus. Supra-optic fibers mostly end in the posterior

lobe, whereas paraventricular fibers also end in the median eminence. Stored hormones

are released by calcium-dependent exocytosis in response to an action potential.

Oxytocin -the action of oxytocin occurs through G-protein coupled receptors of the cell

surface, triggering the increase of intracellular calcium in response to activation.

Oxytocin causes contraction of myoepithelial cells lining the breast ducts. Tactile

29
stimulation of nipples leads to milk flow from the breast's alveoli. Contraction of uterine

smooth muscles during delivery leads to fetal descent and enhances labor, and in the

nonpregnant uterus, it acts by facilitating sperm passage into the fallopian canal. In men,

oxytocin increases at the time of ejaculation and propels sperm towards the urethra by

contraction of the vas deferens smooth muscle.

Vasopressin (ADH- anti-diuretic hormone) acts through cell surface receptors, namely

serpentine, transmembrane, and G protein-coupled receptors, forming a second

messenger and exerting many physiological effects on the body. Vasopressin’s half-life

is 18 minutes.

Acting on collecting ducts, the permeability of the collecting duct is increased by

aquaporin water channel translocation from the endosomal compartment to the luminal

side, enabling water entry to the hypertonic interstitium of the renal pyramid. This leads

to a decrease in urine volume and an increase in urine concentration. Conditions that

increase ADH are decreased blood volume, increased plasma osmotic pressure, increased

angiotensin II levels, pain, emotion, and exercise. ADH secretion is inhibited by alcohol.

Vasopressin is a potent vascular smooth muscle constrictor and also acts by paracrine

action on the anterior pituitary and releases corticotrophin hormones.

30
 LITERATURE REVIEW
HISTORICAL REVIEW

Scholffer in1906 was the first person to remove a pituitary tumor via trans-sphenoidal

approach successfully and was considered to be safe. In 1909, Hirsch used submucosal

resection of the septum and endonasal approach 1910-A.E.

Halstead’s description of sublabial gingival incision for the initial stage of exposure. By

1914, Harvey Cushing combined a sublabial incision with a submucosal septal approach,

preserving nasal functions without an external scar contemporary to Oskar Hirsch,

operated 231 pituitary tumors with a mortality of 5.6%.

Cushing got expertise in transcranial surgery and was able to verify supra-sellar tumor

and achieved decompression of optic apparatus better, resulting in better recovery of

vision and a lower recurrence rate; however, the mortality rate was reduced to 4.5%. As

Cushing influenced neurosurgery worldwide, his shift from the transsphenoidal to

transcranial approach influenced the destiny of pituitary surgery for many years.

For a period of time, the transnasal surgery was abandoned by Cushing himself, and all

other neurosurgeons went in favor of the transcranial approach. Norman Dott, a visiting

scholar, passed through Edinborough, Scotland, because of his work, the lineage that kept

the transsphenoidal procedure alive where others pursued a transcranial approach. Dott

appreciated the merits of transsphenoidal procedure during his stay in Boston from

November 1923 to June 1924. He designed instruments specifically for the

transsphenoidal procedure. In 1956, Gerad Guiot, a pupil of the legendary French

31
Neurosurgeon Clovis Vincent, visited Normann Dott and had a chance to observe

transphenoidal operation.

Guiot introduced intra-operative radiographic control and intra-operative fluoroscopy

during transphenoidal surgery. Guit, in 1958, presented its first few papers on pituitary

adenoma operated on transsphenoidal in front of the French Society of Neurosurgery and

revived the interests of many physicians throughout Europe.

Joules Hardy decided to try the transhenoidal route and was able to perform

hypophysectomies in a dark, deep, and narrow field. He also introduced an operating

microscope for refining the procedure.

The concept of microadenoma was introduced to him and demonstrated surgical cue to

be possible in case of small hyperfunctioning adenomas and significantly increases the

efficacy and surgical morbidity. In 1970, the development of endoscopy occurred; in

1992, Jankowski et al. performed an endoscopic transnasal transsphenoidal approach; in

1996, Jho et al. described an entirely endoscopic transnasal transsphenoidal approach.

32
Figure 7:Hardy Jules. Figure 8: Normann Dott.

Figure 10: Gerad Guiot. Figure 9: Harvey William Cushings.

33
“Pituitary macroadenoma sellar region is a site of various types of tumors. Pituitary

adenomas are the most common. They arise from epithelial pituitary cells and account

for 10-15% of all intracranial tumors. Tumors exceeding 10 mm are defined as

macroadenomas, and those smaller than 10 mm are termed microadenomas. Most

pituitary adenomas are microadenomas”.

Pathophysiology “The cause of pituitary macroadenomas is unknown. The most

acceptable theory attributes the monoclonal neoplastic transformation of pituitary cells

leading to tumor initiation and growth. The monoclonal nature of most pituitary tumors

and their retention of response to negative feedback by hormones produced by target

organs support this hypothesis.”

Pituitary macroadenomas are epithelial tumors, benign in nature, and consist of anterior

pituitary cells. Primary pituitary tumors that are malignant are not expected. Pituitary

adenoma development has an irreversible initiation phase followed by a tumor promotion

phase. Heredity, hormonal, and genetic mutations influence the development of pituitary

macroadenoma. The monoclonal nature of most pituitary tumors indicates that they arise

from a mutated pituitary cell.

34
Hardy's classification of the suprasellar extension of pituitary adenomas

Figure 11: Hardy's classification.

Type-A Tumour with sellar extension, not reaching the optic chiasma

Type-B Tumour reaches the floor of the 3rd ventricle, obliterating the anterior recess of

the 3rd ventricle

Type-C Tumour indents the floor of 3rd ventricle

Type-D Tumour with intradural extension

Type-E Tumour invading the cavernous sinus

35
“The grade A and B tumors were considered easier to excise while the removal of grade

C and D tumors, those that had a superior margin more than 20 mm above the jugum

sphenoidale, was more difficult (40% had residual tumor on the postoperative CT scan).

The coronal images provided additional information regarding the asymmetric lateral

expansion of the tumor (grade D), which technically made a complete excision more

difficult. Wilson's modification of Hardy's system2 introduced a 'stage E' when there was

a direct lateral extension into the cavernous sinus and subsets to 'stage D' when there was

an extension into the anterior, middle, and posterior fossae.”

The transsphenoidal surgical line of vision on a sagittal MRI helps assess the ease of

resectability of pituitary adenomas, especially in Grade C tumors. Depending on the

clinical course, it may be possible to plan either a second-stage transsphenoidal surgery

or a craniotomy when more than 50% of the tumor is above the line of vision.

36
KNOSP classification of parasellar extension

Figure 12: KNOSP classification of parasellar tumour.

Knosp et al3 offered a grading system for showing invasion of cavernous sinus by

pituitary macroadenoma. Briefly, the laterally the adenoma grows and surrounds the ICA,

the higher the grade level is. The relation of carotid lines to the limits of invasion defines

grading. These lines pass through supra- and intra-cavernous parts of ICA in coronal

view. There are medial, median, and lateral carotid lines

Grade 0 –Adenoma did not encroach the cavernous sinus space, not crossing the medial

aspect of intra and supra-cavernous ICA

Grade 1- Tumour crosses medial tangent but does not extend beyond inter carotid line

Grade 2- Tumour crossed beyond intercarotid line but did not cross beyond lateral tangent

of intra and supra cavernous ICA

37
Grade- 3 - Tumour extends beyond the lateral line

Grade-4- Total encasement of intracavernous ICA by tumor

a) Hardy classification system.

Sella turcica tumours can be

1. Noninvasive: grade 0- intact with normal contour; grade I-intact with bulging

floor; or grade II- intact, enlarged fossa or

2. invasive: grade III- localized sellar destruction; or grade IV-diffuse destruction.

Suprasellar tumors can be

1. symmetrical: grade A- suprasellar cistern only; grade B- recess of the third

ventricle; or grade C- whole anterior third ventricle or

2. asymmetrical: grade D- intracranial extradural; or grade E- extracranial extradural

(cavernous sinus).

b) Knosp classification system used to quantify invasion of the cavernous sinus, in which

only grades 3 and 4 define actual invasion of the tumor into the cavernous sinus. Grade

0, no cavernous sinus involvement; in grades 1 and 2, the tumor pushes into the medial

wall of the cavernous sinus but does not go beyond a hypothetical line extending between

the centers of the two segments of the internal carotid artery (grade 1) or it goes beyond

such a line, but without passing a line tangent to the lateral margins of the artery itself

(grade 2); grade 3, the tumor extends laterally to the internal carotid artery within the

cavernous sinus; grade 4, total encasement of the intracavernous carotid artery.

38
Recent imaging techniques, especially MRI, has high sensitivity in detecting aggressive

pituitary tumors, which are usually macroadenomas, but currently, there are no reliable

features distinguishing aggressive from apparently benign' adenomas in the series of

atypical adenomas reported by Zada et al.26 Chatzellis E et al 27 described 94% atypical

adenomas were macroadenomas, and radiological invasion was evident in 83% compared

to 45% of typical adenomas (p = 0.004). Ten lesions (56%) showed infrasellar invasion

with clival or sellar floor erosion, nine (50%) showed suprasellar invasion, and six (33%)

invaded at least one cavernous sinus; in five patients (28%), invasion of all three regions

was noted.

Surgical techniques in complete excision

Indications for surgery •Tumour with mass effect (Macroadenoma: >1cm) –

Chiasmalcompression and objective visual field defect –Raised intracranial pressure

•Pituitary dependant Cushing‟s disease •GH secreting tumour •Prolactinoma –Failure of

medical of treatment –Intolerance of medical management –Pt preference •TSHoma –

Thyrotoxicosis

Endoscopic-assisted transsphenoidal surgery

This procedure is performed using Hopkins rod, a 0 deg telescope, length of 18 cm and

diameter of 0.4 cm, as the sole visualizing instrument of the surgical field; sometimes,

angled scopes are used to further explore the suprasellar area after the lesion removal.

Appropriate surgical instruments with different angled tips are needed for permiting

movements in all the visible corners of the surgical field.28,29 A thorough preoperative

planning by three dimensional reconstructed MRI and/or CT scans, is a road map of

surgery.

39
An image-guided system (neuronavigator) is needed when the classic landmarks are

unidentifiable.

Bipolar endonasal forceps of different diameters and lengths can be easily introduced and

maneuvered in the nasal cavity, and lengthy low-profile drills are useful for opening bony

structures to reach dural space. Finally, the important use of a Doppler probe to protect

the major arteries. Increasing the workspace and the handling of the instruments is

achieved by a) the middle turbinate on one side to be removed, b) lateralization

of the middle turbinate in the other nostril, and c) removal of the posterior part of the

nasal septum. An anterior sphenoidotomy is widely done.

Positioning of the patient

The patient is placed supinely or in a slight Trendelenburg’s position with a turning of

the head 10°–15° on the horizontal plane towards the surgeon. The endoscopic equipment

and the neuro image guiding system are placed behind the patient's head

and in front of the surgeon.30,31,32

An altered combination endoscopic transseptal/transnasal binostril approach in patients

with a narrow space in the nasal cavity for pituitary lesions. This uses a two-surgeon,

four-handed technique can provide a single, wide surgical field by a combination of

septoplasty and nasoseptal flap (NSF) harvestation, which proved to be a genuine and

acceptable method that prevents postoperative cerebrospinal fluid (CSF) leakage

However, standard pituitary surgery does not usually require either the NSF or the two-

surgeon, four-handed technique. In the meantime, this technique provides dynamic

endoscopic movement by an ENT (ear, nose, throat) surgeon that offers a clear and

40
pseudo-three-dimensional visual area and allows manipulation of smooth and

comfortable instruments.

Modified Stamm's approach has the following advantages. 1) suitable for pituitary lesions

associated with narrow nasal spaces, 2) Handling of instruments in and out through the

transseptal route cannot be prevented by the nasal turbinates and/or septal mucosa, 3) the

harvested flap can be used for sellar reconstruction in case of a CSF leak. Finally, it can

collaterally improve patients' symptoms due to chronic nasosinusal diseases. The

disadvantages are time consumption for septal mucosa dissection and can lead to a septal

perforation, transient dental pain, or hyperesthesia. Nasal packing is done to prevent

hematoma formation and promote mucosal healing, leading to patient suffering. The three

different binostril approaches for pituitary lesions are the common binostril approach, the

original Stamm's approach, and the modified Stamm's approach.

Transseptal-Transnasal 1. Killian incision 2. Bilateral flaps 3. Resect posterior septum 4.

Elevate unilateral SN flap 5. Enter sphenoid as in transseptal approach 6. Advantages 7.

Two surgeon ability 8.SN flap reconstruction 9. Preserves contralateral mucosa

The incision is made through a minimally invasive endoscopic procedure. Lengthy

instruments are passed via the nostril while visualizing the monitor. The nasal septum that

divides the left and right nostrils is partly removed. The sphenoid sinus's front wall is

opened with bone-biting instruments' help.

Behind the posterior wall of the sphenoid sinus is the bone overlying the pituitary gland,

known as sella. The dura is exposed by removing the thin bone of the Sella, which exposes

the tumor and pituitary gland.

41
The tumor is removed by the neurosurgeon / ENT surgeons via a small hole in the sella,

in pieces with special instruments called a curette, by coring out the from its center, all

the tumor margins were let to fall inward towards the reach of the surgeon. Once all

removal of the visible tumor is done, the endoscope is advanced into the sella for

inspection of the hidden tumor.

The sella floor was closed by replacing with a bone graft from the septum. Tissue glue is

applied over the graft in the sphenoid sinus.

Peroperative photograph showing (a) exposed sphenoid sinus and of the sellar floor (SF),

tuberculum sellae (TS), planum sphenoidale (PS), lateral and medial carotid recesses,

optic and carotid prominences, and clivus (b)dural exposure of SF, TS, and PS with

superior intercavernous sinus (c) sellar cavity tumor, and (d) covering suprasellar part of

the tumor with its pseudo capsule and arachnoid. (e) endosellar or extraarachnoid

approach for intracapsular removal of intrasellar pituitary adenoma (f) intraarachnoid or

extracapsular removal of suprasellar adenoma (g and h) panoramic (g) and focus view (h)

views of the operative areas after complete tumor removal.

Figure 13: Endoscopic transsphenoidal excision of pituitary macroadenoma per operatively.

42
The endoscopic transsphenoidal approach has evolved considerably in the last 10-15

years and is now the most commonly used surgical procedure for most pituitary

adenomas. Recent studies with this approach have shown increased tumor resection rates

with minimal complications. However, certain adenomas, such as those with dumbbell

configuration, firm or fibrous consistency, or pure suprasellar components, and some

large recurrent tumors are difficult to remove by the conventional endoscopic approach.

As a result, alternative surgical procedures like staged-transsphenoidal, transcranial, or a

combination of transsphenoidal-transcranial approaches have been used for the

management of these subtypes of pituitary tumors. With growing experience in

endoscopic surgery for various skull base lesions, it has now become possible to remove

a wide variety of anterior and middle fossa tumors safely and more effectively.

The advantages of EEEA are many and are mainly because of the wider exposure it

provides after the removal of SF and the bone of the TS and PS. The intradural exposure

achieved by this approach offers simultaneous and direct endosellar and extraarachnoidal

(intracapsular) access to the tumor in the sellar region and suprasellar and

intraarachnoidal (extracapsular) access to the suprasellar part of the tumor. The

intracapsular tumor removal is carried out via the endosellar route and using the

suprasellar corridor at the same time, the tumor capsule is dissected from overlying

suprasellar cistern, OPs, and chiasm, and the anterior cerebral arteries under direct vision.

The basic technique of pituitary macroadenoma surgery involves tumor removal by

curettage and suction method. Although it works well for most pituitary tumors, the

maneuver is ineffective when the tumor is firm and fibrosed. A blind curettage to remove

suprasellar mass from the endosellar route has been found potentially dangerous and is

associated with a high incidence of incomplete tumor removal from the suprasellar region.

43
The standard transsphenoidal surgery for pituitary adenomas also relies mainly on the

spontaneous descent of the suprasellar portion of the tumor into the sellar cavity after

initial tumor debulking by the endosellar route. Occasionally, the suprasellar tumor does

not fall into the sella and causes a large tumor mass to remain in the suprasellar region as

a residue. The EEEA provides different corridors, endosellar and suprasellar, to dissect

the tumor safely from the surrounding structures under direct vision. It also provides

direct visualization and accessibility to suprasellar, subchiasmal, retrochiasmal, and

retrosellar regions which are generally poorly visible in the standard transsphenoidal

surgery.

In cases of dumbbell tumors, a narrow diaphragma opening prevents the descent of the

suprasellar portion of the tumor into the sellar cavity. The fibrous tumors, recurrent

tumors after initial surgery or irradiation, and some medically treated large tumors fail to

fall into the sellar cavity because of their firm consistency and are, therefore, less likely

to be removed totally by the routine transsphenoidal route. The EEEA is advantageous in

these cases because it offers larger tumor exposures through two different routes,

endosellar or extraarchnoidal and suprasellar or intraarachnoidal, which facilitates entire

tumor removal in a single-stage surgery. Purely suprasellar tumors and some giant tumors

with large midline extensions in the subfrontal regions are not adequately visualized via

the endosellar route and are, therefore, clearly unsuitable for the standard transsphenoidal

approach. Adding a trans-tubercular-transplant extension to the regular transsphenoidal

endo-sellar approach considerably increases the possibility of tumor removal from these

areas. Both patients in our series had primary suprasellar residual tumors, and one of the

two patients, who had giant pituitary tumors with large subfrontal extensions, had a

complete resection of their adenomas.

44
After endoscopic surgery, the hospital stay is one or two days. During this period, nurses

will change dressings and help the patient with bathroom needs. Patients can return to a

regular diet if they take fluids well. Patients are encouraged to leave bed and walk as soon

as possible. While in the hospital, patients will be asked to help their nurses keep track of

the amount of fluids they drink and their urine output to evaluate pituitary function.

Home care may include:

• Analgesics to control headaches, the most common complaint after surgery

• Lifting weights or straining for stools are allowed until the doctors give clear

advice.

• Follow-up visits with your endocrinologist and surgeons

• MRI has to be repeated

• Eye testing

• It is important to let your doctors know about:

• Any headache that doesn't go away with medication

• Nausea and vomiting

• Fever

• epistaxis

• Watery discharge from the nose

• Increase in frequency of urination

45
 4
Karamouzis et al. presents a retrospective study examining the early outcomes of

endoscopic transsphenoidal surgery for pituitary adenomas at a single institution in Italy.

The authors found that endoscopic surgery was generally safe and effective, with a low

rate of major complications. Consistent with other sources you've shared, they observed

that the most common complication was diabetes insipidus. Additionally, the study

reports that visual function improved in most patients after surgery, but the recovery of

pituitary function was less frequent. These findings contribute to the growing body of

literature supporting the use of endoscopic techniques in pituitary surgery, while also

highlighting that complete recovery of pituitary function is not always achievable, even

with successful tumor removal. The study emphasizes that tumor characteristics, such as

invasion of the cavernous sinus and tumor size, can influence surgical outcomes. This

underscores the importance of considering these factors when evaluating patients for

surgery and counseling them about potential risks and benefits.

5
Dixit et al. investigates the effectiveness and potential complications of endoscopic

endonasal transsphenoidal pituitary surgery (EETS) based on a study of 30 patients at a

tertiary care institution. The study highlights that EETS resulted in gross total tumor

removal in a significant portion of the patients (60%), aligning with the positive outcomes

reported in other sources you've shared. It also notes the occurrence of temporary diabetes

insipidus and CSF rhinorrhea in some patients, common complications associated with

this type of surgery, as observed in other sources you've provided. The authors' conclusion

that EETS is a viable and cost-effective treatment option, especially for complex tumors,

resonates with the broader discussion in the field, evident in several other sources you've

presented, emphasizing the procedure's safety, efficacy, and advantages over traditional

approaches.

46
Hajdari et al.6 presents a comparative study evaluating the effectiveness of three different

endoscopic visualization systems (2D-HD, 3D-SD, and 3D-HD) in endoscopic endonasal

transsphenoidal surgery (EETS) for pituitary adenomas. Interestingly, while the study

acknowledges the theoretical advantages of 3D visualization in enhancing depth

perception and hand-eye coordination, the findings indicate that these benefits didn't

translate into statistically significant differences in key surgical outcomes, including gross

total resection rates, new hormonal deficits, or complications, across the three

visualization techniques. This aligns with observations from other studies mentioned in

our conversation, suggesting that the choice between 2D and 3D systems might not

drastically impact objective surgical results for this specific procedure. However, the

source highlights that surgeons using the 3D-HD endoscopes reported experiencing better

dexterity and surgical comfort, hinting at potential ergonomic benefits associated with 3D

visualization. This resonates with the broader discussion in the field, as indicated by other

sources we've reviewed, regarding the potential of 3D technology to improve surgeon

experience and potentially indirectly enhance patient care, even if direct, statistically

significant improvements in surgical outcomes remain a subject of ongoing investigation.

Jho et al.7 describes the authors' early experience using endoscopes in transsphenoidal

surgery for pituitary adenomas. The authors explain that they were inspired to use

endoscopes in this type of surgery based on their positive experiences using the

instruments in paranasal sinus surgery. The article describes the authors' technique for

endoscopic transsphenoidal surgery, which they have used in 45 patients with pituitary

adenomas. The technique involves accessing and removing the pituitary adenoma through

a nostril using a 4mm rigid endoscope. The authors report that their short-term surgical

results with this technique have been encouraging, with patients experiencing short

47
hospital stays and minimal morbidity. The article provides a detailed account of the

endoscopic technique they use, illustrated by two cases of pituitary adenomas. This source

highlights the early interest in and potential benefits of using endoscopes in

transsphenoidal pituitary surgery, which aligns with the positive findings regarding the

endoscopic approach discussed in other sources you've shared.

Chavez-Herrera et al.8 provides a comprehensive overview of the evolution and current

state of endonasal endoscopic surgery for pituitary adenomas. The authors trace the

historical progression of surgical approaches to pituitary adenomas, from early

transcranial methods to the development and refinement of transsphenoidal techniques,

highlighting the pivotal role of endoscopic technology in revolutionizing this field. The

article emphasizes the advantages of the endoscopic approach, including a wider surgical

view, improved illumination, and the ability to access previously challenging areas. It

discusses the surgical anatomy relevant to the procedure, pre-operative considerations,

and the fundamental concepts of endoscopic endonasal surgery. The article also addresses

potential complications, like CSF leaks, and details reconstruction techniques aimed at

minimizing these risks. The authors conclude by emphasizing that the adoption of

endoscopy has significantly improved the surgical management of pituitary adenomas,

offering patients safer and more effective treatment options.

Cavallo et al.9 offers a detailed technical guide to performing endoscopic endonasal

surgery for pituitary adenomas, emphasizing the anatomical knowledge and surgical

techniques involved. The authors, drawing on their experience at the Division of

Neurosurgery at the Universita’ degli Studi di Napoli “Federico II”, provide a step-by-

step explanation of the procedure, from patient positioning and surgical setup to the

48
intricacies of tumor removal and reconstruction of the surgical site. The article highlights

the advantages of the endoscopic endonasal approach, including reduced patient

discomfort and improved visualization for the surgeon. It emphasizes the importance of

understanding the relevant anatomy, particularly within the sphenoid sinus, and details

the steps taken to minimize complications, such as damage to the sphenopalatine artery.

The authors also discuss specific challenges, like managing pituitary adenomas extending

into the cavernous sinus, and describe their preferred reconstruction techniques to ensure

optimal outcomes. While acknowledging that the procedure is technically demanding,

they conclude by advocating for its use based on its safety, efficacy, and ability to improve

patient care.

Lopez at al.10 details the findings and outcomes of a retrospective study conducted at a

single hospital to assess the effectiveness of the endoscopic endonasal approach (EEA)

for pituitary adenoma resection. The study, encompassing 80 patients treated between

2011 and 2019, reveals an encouraging gross total resection rate of 76.2% for tumors

without cavernous sinus invasion. This success rate aligns with findings from other

studies we've reviewed, further supporting the efficacy of EEA in treating pituitary

adenomas. The study underscores that EEA, particularly when coupled with a

multidisciplinary management approach, offers a safe and effective treatment modality

for pituitary adenomas. The authors emphasize that this technique allows for a wide

surgical view, good illumination, and access to challenging areas, contributing to its

effectiveness. The study reports that a significant proportion of patients (88.6%) with

visual deficits experienced improvement following the procedure. However, echoing

observations from previous studies we've discussed, complete recovery of pituitary

function was less frequent, with 18.75% of patients developing new hormonal deficits

49
post-surgery. The study also highlights common complications associated with EEA,

including CSF leaks (12.5%) and new hormonal deficits (18.75%). The authors

emphasize that minimizing these complications requires meticulous surgical execution,

informed by a thorough understanding of surgical anatomy and a focus on minimizing

trauma to surrounding structures. They also acknowledge the role of the learning curve

in refining surgical techniques and reducing complication rates.

Fallah et al.11 examines the surgical outcomes of endoscopic endonasal surgery (EETA)

for treating large and giant pituitary adenomas. The study, conducted at Imam Khomeini

Hospital in Tehran, Iran, involved 80 patients who underwent EETA for these types of

tumors. Notably, the study reports a high gross total resection rate of 82.5% using this

approach, a figure that aligns with the positive outcomes reported in other sources we've

reviewed regarding the efficacy of endoscopic techniques in pituitary adenoma surgery.

The article emphasizes that EETA offers a safe and efficient primary treatment option for

these complex cases, leading to significant improvement in visual function for the

majority of patients (76.8% with visual acuity impairment and 74.1% with visual field

deficits). The authors acknowledge potential complications, including new pituitary

insufficiency (16.4%), permanent diabetes insipidus (7.5%), and cerebrospinal fluid

leakage (5%), which are consistent with the risks discussed in other sources we've

examined. The study concludes that EETA, by providing superior visualization of the

surgical field and surrounding structures, allows for maximal tumor resection with a

relatively low complication rate.

This narrative review article by Guinto et al.12 examine the use of transsphenoidal surgery

to treat pituitary adenomas. While transsphenoidal resection is a standard treatment for

50
this condition, experts are still debating whether the microsurgical or endoscopic

approach is better. The increasing popularity of endoscopic transsphenoidal surgery has

led to many studies comparing the two, but no definitive answer has emerged. This review

considers the advantages and disadvantages of both approaches from a technical

perspective and within the context of existing research. The authors emphasize that

because surgical expertise and multidisciplinary management have such a significant

impact on patient outcomes, treatment decisions should be made on a case-by-case basis

with careful consideration of the individual patient's needs.

Jho et al.13 presents the findings of a study on the use of endoscopic endonasal

transsphenoidal surgery to treat a variety of pituitary lesions, particularly pituitary

adenomas. The study involved 50 patients with a median age of 38 years. The authors

reported that this surgical approach resulted in minimal discomfort and unobstructed

nasal airways for all patients after surgery, with most requiring only an overnight stay in

the hospital. The study found that endoscopic endonasal transsphenoidal surgery was

successful in resolving hypercortisolism in a majority of patients with Cushing's disease,

and also led to clinical improvement and normalization of serum prolactin levels in many

patients with prolactinomas. The authors conclude that the endoscopic endonasal

approach to transsphenoidal surgery represents an effective and safe method for treating

pituitary lesions.

A review article by Cappabianca et al.14 examines the evolution and adoption of

endoscopic endonasal transsphenoidal surgery as a treatment for pituitary lesions. The

authors trace the history of this approach from its introduction in 1963 to its modern-day

prevalence, noting that technological advancements and the collaborative efforts of

51
neurosurgeons and otolaryngologists have been instrumental in its rise to prominence.

The authors highlight the advantages of the endoscopic approach over traditional

microsurgical techniques, including a superior, magnified view of the surgical field, a

wider working angle, and less invasiveness. They cite studies demonstrating that

endoscopic surgery results in similar rates of tumor removal and symptom relief, with the

added benefit of improved patient satisfaction. The authors conclude that endoscopic

endonasal transsphenoidal surgery has become a well-established and widely accepted

approach for treating pituitary lesions, offering both surgeons and patients a safe and

effective alternative to traditional microsurgical methods.

A study conducted by Gondim15 examines the results of 228 patients who underwent

endoscopic endonasal transsphenoidal adenoma removal at a pituitary center over a 10-

year period. The study found that gross total removal was achieved in 79.3% of cases,

with a median follow-up of 61.5 months. Remission rates were 83% for nonfunctioning

adenomas and 76.3% for functioning adenomas. The authors reported a 13.9% rate of

postoperative complications, most of which were temporary, and no deaths related to the

procedure. They conclude that the endoscopic endonasal approach is a safe and effective

alternative to microscopic surgery, offering excellent tumor removal rates and a less

invasive approach with fewer complications.

Yano et al.16 investigated the effectiveness of the endoscopic endonasal transsphenoidal

approach through the bilateral nostrils for treating pituitary adenomas. The study involved

a retrospective analysis of 194 patients who underwent 213 procedures from December

2001 to March 2008. The surgical approach involves accessing the pituitary gland

through both nostrils with minimal or wide dissection of the septal mucosa based on the

52
size and spread of the tumor. The researchers used various tools, including

neuronavigation and real-time hormone monitoring, during the procedures. The results

showed high tumor removal rates, particularly in nonfunctioning adenomas, with

significant improvement in removal rates between 2005-2008 compared to 2002-2004.

The procedure also led to endocrinological remission in a notable number of patients with

growth hormone-secreting tumors, microprolactinomas, and Cushing's disease. Although

the study reported some postoperative complications, such as cerebrospinal fluid leakage

and visual impairment, it concluded that the bilateral endonasal approach is a viable

option for treating pituitary adenomas, especially larger ones, due to its wide surgical

field, flexibility, minimal invasiveness, and potential for improved outcomes with tools

like neuronavigation and hormone monitoring.

Zhang et al.17 examines the effectiveness of endoscopic endonasal transsphenoidal

surgery, a minimally invasive technique, in treating invasive pituitary adenomas (IPAs).

The researchers retrospectively reviewed data from 78 IPA patients, analyzing diagnostic

methods, surgical techniques, and patient outcomes. The results showed a high rate of

complete tumor removal (79.5%) and significant improvement in clinical symptoms,

including visual impairment, in most patients. The study concludes that this surgical

approach offers several benefits, such as excellent visualization of the surgical field,

shorter procedure times, and minimal postoperative complications, making it a safe and

effective treatment option for IPAs.

This review article by Yadav et al.18 advocates for the adoption of endoscopic endonasal

transsphenoidal surgery (EETS) as a safe and effective treatment for pituitary adenomas.

The authors highlight the benefits of EETS, such as minimal invasiveness, reduced blood

53
loss, shorter operating times, and improved patient outcomes compared to traditional

microscopic techniques. They emphasize the importance of preoperative imaging (CT

and MRI scans) and intraoperative endoscopic visualization for surgical planning. The

article discusses the use of advanced technologies like neuronavigation, ultrasonic

aspirators, and high-definition cameras to enhance surgical precision and safety.

Additionally, the authors recommend a multidisciplinary approach involving

neurosurgeons and otolaryngologists, along with proper patient selection, to minimize

complications. The article concludes that EETS, particularly when combined with

comprehensive training and specialized pituitary centers, represents a superior surgical

option for most pituitary adenomas.

Hofstetter et al.19 examines the factors that influence the success of endoscopic endonasal

surgery for certain types of pituitary adenomas. The authors retrospectively analyzed data

from 86 patients with therapy-resistant pituitary adenomas who underwent this procedure.

The study found that the size and location of the tumor significantly affected the

likelihood of achieving endocrinological remission. Specifically, smaller tumors

(microadenomas) and those confined to the pituitary gland had higher cure rates

compared to larger tumors (macroadenomas) and those extending beyond the pituitary

gland, such as into the cavernous sinus. The study reports high cure rates for

prolactinomas and good cure rates for GH-secreting tumors and ACTH-secreting tumors.

The authors emphasize the importance of considering tumor characteristics and achieving

complete tumor removal for optimal outcomes in endoscopic endonasal surgery for

functional pituitary adenomas.

54
Messerer et al.20 discusses endoscopic endonasal trans-sphenoidal surgery as a minimally

invasive approach to treating pituitary adenomas and other pituitary lesions. The authors

state that this surgical technique has become the gold standard for treating these

conditions, thanks to its low complication rates and excellent results. The article aims to

provide a step-by-step guide to this procedure, based on the authors' personal experience,

and highlight its effectiveness as a minimally invasive surgical option.

Fallah et al.21 conducted a study that examined the safety and efficacy of the extended

endoscopic transsphenoidal approach (EETA) in treating large and giant pituitary

adenomas. The researchers conducted a retrospective analysis of 80 patients who

underwent EETA for these types of tumors. The study found that EETA resulted in high

rates of gross total resection (82.5%) and significant improvement in vision in a majority

of patients. The study also reported a relatively low rate of complications, including new

pituitary insufficiency, diabetes insipidus, and cerebrospinal fluid leakage. The authors

conclude that EETA is a safe and effective first-line treatment option for large and giant

pituitary adenomas, offering favorable outcomes in terms of tumor resection, visual

function improvement, and complication rates. The study also highlights that factors like

tumor size, shape, and Knosp score can influence the likelihood of achieving complete

tumor removal.

Lopez at al.22 examined the outcomes of 80 patients who underwent endoscopic endonasal

approaches (EEA) for pituitary adenoma resection at a single center between 2011 and

2019. The researchers aimed to evaluate the safety and effectiveness of this surgical

approach. The study found that gross total resection was achieved in 76.2% of patients

who did not have cavernous sinus invasion. Additionally, 88.6% of the 53 patients

55
presenting with vision loss experienced improvement or normalization of their vision

following the procedure. The most common complication was CSF leak, occurring in

12.5% of patients, followed by new hormonal deficit (18.75%) and epistaxis (6.25%).

The authors conclude that EEA is a safe and effective approach for pituitary adenoma

resection when performed by well-trained surgeons, with results comparable to those

reported in previous studies using microscopic or endoscopic techniques.

56
 MATERIALS AND METHODS
The study was conducted at the Government Rajaji Hospital, Madurai Medical College,

in the Department of Oto-Rhino-Laryngology, in collaboration with the Department of

Neurosurgery, from November 2022 to November 2023.

The study was a prospective study.

The study population comprised patients who were diagnosed with pituitary adenoma.

Cases of pituitary adenoma attending neurology OPD, neurosurgery OPD, and surgical

endocrinology OPD cases were referred to the Department of Otorhinolaryngology,

Government Rajaji Hospital, Madurai Medical College.

Patients who satisfied the inclusion criteria were studied. The inclusion criteria for

selecting the study group were all cases fit for surgery, newly diagnosed cases, and

recurrent cases. The exclusion criteria were the cases of extreme age group, poor general

conditions, and cases having comorbid conditions that are not fit for surgery.

The sample size for this study was 30.

CT scan and MRI was done. Institutional Ethical clearance and informed consent were

obtained. Data regarding patient age, sex, type of tumor, modes of presentation, tumor

consistency, tumor intensity, and tumor extension based on MRI T2 weighted images,

preoperative findings, tumor excision, perioperative complications, postoperative

complications, management of complications, and post-operative recurrences was

collected.

57
The data was entered in an Excel sheet, and analysis was done using the Python

programming language.

Descriptive statistics like mean, standard deviation, and proportion were used to express

the study characteristics.

The Chi-square test was used to find an association between the MRI T2 weighted images

based on consistency and tumor extension with surgery. Implication. A p-value <0.05

was considered as significant.

58
 OBSERVATIONS AND RESULTS
A total of 30 cases were studied. The details of all the cases are given in the master chart.

The following observations were made and analyzed. The age range of the study

population was 20 to 60. Their mean age was 44.5 years, and the standard deviation was

10.

TABLE 1: AGE DISTRIBUTION OF STUDY POPULATION.

Age groups in years Number individuals Percentage

20-30 3 10%
31-40 5 17%
41-50 12 40%
51-60 10 33%
Total 30 100%

Figure 14: Age distribution of the study population.

• The majority of the pituitary macroadenomas were seen in the age group 41-50

years (40%).

59
TABLE 2: SEX DISTRIBUTION OF THE STUDY POPULATION.

Sex Number of Individuals Percentage

Male 12 40%
Female 18 60%
Total 30 100%

Figure 15: Sex distribution of the study population.

• The total number of females were 18 (60%) and males were 12 (40%).

60
TABLE 3: TYPES OF PITUITARY ADENOMA.

Types of pituitary Number of Individuals Percentage

adenoma (Hormone
secreting / non-hormone
secreting)
Secretory 10 33%
Non secretary 20 67%
Total 30 100%

Figure 16: Types of pituitary adenoma of the study population.

• All the pituitary macroadenomas were divided into nonsecretory and secretory

groups. Among the 30, nonsecretory was 20 (67%), and secretory was 10 (33%).

61
TABLE 4: TYPES OF PITUITARY ADENOMA (SIZE).

Types of pituitary adenoma Number of Individuals Percentage

(size)

Micro adenoma 2 6.67%

Macro adenoma 28 93.33%

Total 30 100%

Figure 17: Types of pituitary adenoma (size).

• All the pituitary adenomas were divided into microadenoma and microadenoma

groups. Among the 30, microadenoma was 2 (6.67%), and secretory was 28

(93.33%).

62
TABLE 5: AGE-WISE DISTRIBUTION OF TYPES OF PITUITARY
ADENOMA.

Age group in years Type of pituitary microadenoma Total

Secretory Non-secretory

20-30 1 (3.33%) 2 (6.67%) 3 (10.00%)

31-40 4 (13.33%) 1 (3.33%) 5 (16.67%)
41-50 3 (10.00%) 9 (30.00%) 12 (40.00%)
51-60 2 (6.67%) 8 (26.67%) 10 (33.33%)
Total 10 (33.33%) 20 (66.67%) 30 (100.00%)

Figure 18: Types of Pituitary adenoma (secretory/non-secretory)

• Among the secretory and nonsecretory tumor types, the majority were present in

the age groups 31-40 years and 41-50 years, respectively.

63
TABLE 6: SEX-WISE DISTRIBUTION OF TYPES OF PITUITARY
ADENOMA.

Sex Type of pituitary macroadenoma Total

Secretary Non-Secretory

Male 2 (6.67%) 10 (33.33%) 12 (40.00%)

Female 8 (26.67%) 10 (33.33%) 18 (60.00%)
Total 10 (33.33%) 20 (66.67%) 30 (100.00%)

• Non-secretory type tumors were present in both males and females, with 10 each

(33.33%). Secretory-type tumors were more common in females, with

8 (26.67%).

64
TABLE 7: NEW OR RECURRENT CASES.

New/Recurrent cases Number of Individuals Percentage

Recurrent cases 3 10%
New cases 27 90%
Total 30 100%

Figure 19: New/Recurrent cases

• Among the study population, 27 (90%) were new cases, and 3 (10%) were
recurrent cases.

65
TABLE 8: MODES OF PRESENTATION OF PITUITARY ADENOMA.

Modes of presentation* Number of Individuals Percentage

Headache 28 93.33%
Prolactinoma 3 10.00%
Visual defects 9 30.00%
Acromegaly 3 10.00%
Cushing Syndrome 2 6.67%
Apoplexy 0 0%

*Multiple response

Figure 20: Mode of presentation.

• Our study's predominant symptoms were headaches 28 (93.33%) and visual

defects 9 (30%). Out of 3 cases of prolactinoma, 2 cases presented with

galactorrhoea, and 1 case presented with gynaecomastia and loss of libido. 3

(10%) cases were presented as acromegaly, and Cushing syndrome was seen in 2

(6.67%) cases. No apoplexy was seen in the cases presented.

66
TABLE 9: TUMOUR CONSISTENCY BASED ON MRI-WEIGHTED IMAGES.

Tumour consistency Number of Individual Percentage

Cystic 4 13%
Semisolid 10 33%
Solid 16 53%
Total 30 100%

Figure 21: Tumour consistency based on MRI-weighted images.

MRI-weighted images showed that 53% (16), 33% (10), and 13% (4) of the tumours were

solid, semisolid, and cystic, respectively.

67
TABLE 10: TUMOUR EXTENSION BASED ON MRI-WEIGHTED IMAGES.

Tumour extension Number of individuals Percentage

Sellar 8 27%
Sellar and Suprasellar 18 60%
Sellar and Parasellar 1 3%
Sellar, suprasellar and 3 10%
parasellar
Total 30 100%

Figure 22: Tumour extension based on MRI-weighted images.

The majority of tumor extension was to the sellar and suprasellar regions 18 (60%), and

in Sellar 8 (27%), sellar, suprasellar, and parasellar regions in 3 (10%). Tumour was

limited to sellar and parasellar region in 1 case (3%).

68
TABLE 11: SURGICAL IMPLICATION OF CONSISTENCY BASED ON MRI-
WEIGHTED IMAGES.
Consistency Tumour consistency per operative Chi- P value
based on square
MRI value
Cystic Firm Soft Total
Semisolid 0 (0.00%) 4 (13.33%) 6 (20.00%) 10 (33.33%)

Solid 0 (0.00%) 14 (46.67%) 2 (6.67%) 16 (53.33%) <0.05

21.6 (Significa
Cystic 4 (13.33%) 0 (0.00%) 0 (0.00%) 4 (13.33%) nt)

Total 4 (13.33%) 18 (60.00%) 8 (26.67%) 30 (100.00%)

Figure 23: Surgical implication of consistency based on MRI-weighted images.

Tumour consistency peroperative, the consistency of 10 tumours was semisolid of which,

on peroperative findings, 8 (26.67%) were soft, and 18 (60%) were firm, 4 (13.33%) were

cystic. Cystic consistency based on MRI images was similar to the preoperative findings.

Cystic tumours were removed by suction.

69
TABLE 12: SURGICAL IMPLICATION OF TUMOUR EXTENSION BASED
ON MRI-WEIGHTED IMAGES.

Tumour extension per operative Chi- P value

Tumour squared
extension
based on MRI Similar Not Similar Total
Sellar 8 (26.67%) 0 (0.00%) 8 (26.67%)

Sellar and 2 (6.67%) 18 (60.00%)

16 (53.33%)
Suprasellar

Sellar and 1 (3.33%) 0 (0.00%) 1 (3.33%)

<0.05
Parasellar 0
(Significant)
Sellar, 3 (10.00%) 0 (0.00%) 3 (10.00%)
suprasellar and
parasellar

Total 28 2 (6.67%) 30 (100.00%)

Figure 24: Surgical implication of tumour extension based on MRI-weighted images.

Sellar and suprasellar extension on MRI were similar in 18 (53.33%) cases per-

operatively, and 4 cases showed extension of tumour laterally (para sellar) without carotid

70
encasement or cavernous sinus invasion. Suprasellar and para sellar extension on MRI

were similar in 14 cases, whereas 2 cases were not similar to the peroperative findings.

TABLE 13: KNOSP’s grading of tumour:

Grade Number of Individuals Percentage

Grade 0 6 20%

Grade 1 17 56.66%

Grade 2 4 13.33%

Grade 3 3 10%

Total 30 100%

Figure 25: KNOSP’s grading of tumour

71
TABLE 14: PER OPERATIVE COMPLICATIONS

Peroperative Complication Number of Individuals Percentage

Nil 27 90%

CSF leak 3 10%

Total 30 100%

Figure 26: Per operative complications

CSF leak was the only peroperative complication found in 3 cases (10%).

72
TABLE 15: EXCISION OF TUMOUR:

Tumour excision Number of Individuals Percentage

Complete 24 80%

Incomplete 6 20%

Total 30 100%

Figure 27: Excision of tumour.

Complete excision was performed in 24 cases (80%), whereas incomplete excision was
in 6 cases (20%).

73
TABLE 16: POST-OPERATIVE COMPLICATION.

Post-operative Number of Individuals Percentage

complication*
Nil 21 68%
Diabetes insipidus 4 13%
Pneumoencephalocoel 1 3%
CVA 2 6%
CSF leak 3 10%
*Multiple response

S a

Pn umo n ao o

ia t s insi idus

Ni

Num r of ati nts

Figure 28: Post operative complications.

The most common postoperative complication was diabetes insipidus in 4 cases (13%).

Pneumoencephalocoel was seen in 1 case (3%), CSF leak was observed in 3 cases (10%),

and CVA was noted in 2 cases (6%).

74
TABLE 17: MANAGEMENT OF COMPLICATIONS.

Management of Number of Individuals Percentage

complications*
Nil 24 80%
CSF leak repair 0 0%
Desmopressin 4 13%
CVA conservative
2 7%
management
Lumbar drain 0 0%

*Multiple response

Figure 29: Management of complications.

Peroperative CSF leak repair was done for 3 cases (10%). Post operative diabetes

insipidus was treated with desmopressin in 4 (13%) cases. CVA was managed

conservatively in 2 cases (6.7%).

75
TABLE 18: RELATIONSHIP BETWEEN TUMOUR EXTENSION AND
HEADACHE.

Tumour extension on MRI Headache Total

Present Absent

Sellar 8 (27%) 0 (0.00%) 8 (27%)

Sellar and Suprasellar 16 (53%) 2 (7%) 18 (60%)
Sellar and Parasellar 1 (3%) 0 (0.00%) 1 (3%)
Sellar, suprasellar and parasellar 3 (10%) 0 (0%) 3 (10%)
Total 28 (93%) 2 (7%) 30 (100%)

Figure 30: Relationship between tumour extension and headache.

Among 18 (60%) cases with sellar and suprasellar extensions, 16 (53%) presented with

headache and all the 12 (40%) cases with sellar, sellar and parasellar, sellar, suprasellar

and parasellar extensions presented with headache.

76
TABLE 19: RELATIONSHIP BETWEEN TUMOUR EXTENSION AND
VISUAL DEFECT.

Tumour extension on MRI Visual defect Total

Present Absent

Sellar 3 (10%) 5 (17%) 8 (8%)

Sellar and Suprasellar 5 (17%) 13 (43%) 18 (60%)
Sellar and Parasellar 0 (0%) 1 (3%) 1 (3%)
Sellar, suprasellar and parasellar 1 (3%) 2 (7%) 3 (10%)
Total 9 (30%) 21 (70%) 30 (100%)

Figure 31: Relationship between tumour extension and visual defect.

Visual defects were present in 9 (30%) cases.

77
SELLAR EXTENSION OF PITUITARY ADENOMA

Figure 32

SELLAR AND SUPRASELLAR EXTENSION

Figure 33: Sellar and suprasellar extension.

78
SELLAR AND PARASELLAR EXTENSION

Figure 34

79
RECURRENT PITUITARY MACROADENOMA

Figure 35

PITUITARY APOPLEXY

Figure 36

80
Figure 37: A case of pituitary macroadenoma with acromegaly.

81
Figure 38: Before surgery.

Figure 39: After surgery.

82
 DISCUSSION
The present study was undertaken on 30 patients who sought treatment in the department

of ENT, Madurai Medical College, and Government Rajaji Hospital, Madurai.

In our study, the mean age of the population was 44.5 years and standard deviation was

10. Most pituitary macroadenomas were seen in the age group 41-50 years (40 %).
23
Cawich S et al. found in their study the mean age was 45.4 years (SD +/-14.8). The

females constituted 60% (18) and males 40% (12) in our study, which was similar to a

study conducted by Cawich S et al. 23

The nonsecretory type of pituitary macroadenomas was more predominant 20 (67%) than

the secretory type 10 (33%) in our study. According to Cawich S et al., 55% were

nonsecretory, and 44.4% were of the secretory type. Castro MC6 et al., in their study,

found non-secreting type in 96 (74.42%) and secreting in 33 patients (22.58%). Our

study's predominant symptoms were headache 28 (93.33%) and visual defects 9 (%),
23
whereas Cawich et al. reported visual defects as the predominant symptom followed
24
by headache. Castro MC et al. reported acromegaly and galactorrhoea in their study,
25
while Matsuyama et al. , in his study, found visual defects as the predominant

symptoms, followed by headache, galactorrhoea, and acromegaly.

The signal intensity of MRI based on T2 weighted images was 40% hyperintense,33%

isointense, and 27% hypointense, according to Heck A et al. 26, in contrast in our study,

the signal intensity of MRI based on T2 weighted images was 16 (53%) hyperintense, 10

(33%) isointense, and 4 (13%) hypointense.

83
Yamamoto et al. 27 reported 62 .06% of tumors were solid and 37.93% were semisolid in

a comparative study of solid and semisolid types of pituitary macroadenoma. In contrast,

our study found 10 (33%) were semi-solid and 16 (53%) were solid tumors. Out of 10

(33.33%) semisolid tumours on MRI T2 WI, 6 (20%) were soft, and 4 (13.3%) cases were

hard preoperatively. Among 16 (53.33%) solid tumors on MRI T2 WI, 14 (46.67%) were

found to be hard, and the remaining 2 (6.67%) were soft per operatively, according to

Yamamoto et al., they also found that there was no significant correlation between tumor

consistency at the time of surgery and T2WI.

On MRI-based images, the consistency of 10 tumors was semisolid, of which on

preoperative findings, 6(60%) were soft, and 4(40%) were firm. 16 (53.33%) of the

tumors having solid consistency on MRI-weighted-based images were firm, and the

remaining 2 (6.67%) were found to be soft per operative findings. Cystic consistency

based on MRI images was similar to the preoperative findings. Ramakrishnan VR28 found

that of the 106 patients included in the study, seventy-one (67%) showed suprasellar

extension of their tumor. Various studies revealed parasellar invasion by a pituitary

adenoma is clinically significant and occurs in 6 to 10% of cases.29

The majority of tumor extension was to the sellar and suprasellar regions 18 (60%), sellar

in 8 (27%), 1 (3%), the tumor extension was seen in both the sellar and parasellar regions

and 3 (10%) to sellar, suprasellar and parasellar extension. Sellar and suprasellar

extension on MRI was similar in 16 (53.33%) cases peroperatively, and 3 (10%) cases

showed extension of tumor laterally (para sellar) without carotid encasement or cavernous

sinus invasion. Sellar and parasellar extensions on MRI were similar in only 1 case

(3.33%). whereas in 8 cases (26.67%) of sellar were similar to the per-operative findings.

Assessing the parasellar extension of a macroadenoma is important in evaluating the

84
preoperative MRI study. There are few indicators of para-sellar involvement since clinical

features occur late, and subsequent examination of histologic and molecular tumor

markers inconsistently correlated with para-sellar invasion. 30

According to Hardys’ classification, the grade A and B tumors were considered easier to

excise while the removal of grade C and D tumors, those that had a superior margin more

than 20 mm above the jugum sphenoidale, was more difficult (40% had residual tumor
3
on the postoperative CT scan). Knosp et al. offered a grading system for showing

invasion of cavernous sinus by pituitary macroadenoma. Briefly, the laterally the

adenoma grows and surrounds the ICA, the higher the grade level is. The relation of

carotid lines with the limits of invasion defines the grading. Thereby, en masse dissection

is possible only when the tumor lies with minimal or no suprasellar extension and also
31
lies between the carotid. Lopez Arbolay et al., , in their study, noted gross tumor

removal is seen in 92.4% and subtotal resection in 7.8%. by endonasal endoscopic

transsphenoidal surgery. Fan YP et al. 32 reported among 28 patients, total resection was

done in 16 patients, subtotal resection (the extent of removal was > 90%) in 8 patients,

partial resection in 3 patients, and biopsy in 1 due to excessive bleeding and hard nature.

A complete excision was done in 24 (80%) of the cases, and the remaining 6 (20%)

involved an incomplete excision of the tumor. Complete resection is done in all cases

where there is the proper dissection plane with no or minimal suprasellar extension, and

en masse resection is also possible only when the tumor lies within the carotid.

In our study, CSF leak was the only per-operative complication found in 3 cases (10%),

and the most common post-operative complication noted was diabetes insipidus in 4

85
(13%) cases. In 1 case, pneumoencephalocoel along with CSF leak, and in 2 cases, CVA

was noted.

24
Castro MC et al. found the main complications found in patients were CSF

fistulas in 8.5%, meningitis in 3.1%, and one death due to major intracerebral hemorrhage

in the postoperative period. As complications, transient diabetes insipidus in 13 cases

(33.3%), cerebrospinal fluid leakage in 3 cases (7.7%), and subarachnoid hemorrhage in

1 case (2.6%) were observed by Matsuyama et al.25

The low rate of complications depends on several factors, such as the extension

of the tumoral resection, the type of tumor, and the preservation of the structures around

the injury (hypophysis, cavernous sinus, suprasellar space).

Matsuyama et al25 in the study, observed CSF fistulas that occurred in eleven patients

were cured by conservative treatment in seven cases (5.53%), and four patients (3.1%)

were reoperated through the endoscopic approach to close the fistula. Meningitis

complication was managed with antibiotics therapy.

In our study, preoperative CSF leak repair was done for 3 (10%) cases by

multilayer closure done by sealing with fat, cartilage, nasal septal flap, surgical, and tissue

glue followed by nasal packing done with merocel and kept insitu for one week. The post-

operative period was uneventful, and the pack was removed after a week by doing a

diagnostic nasal endoscopy in our operation theatre under aseptic conditions. No leak was

observed in those cases. For 3 (10%) case, which was a recurrent case, after incomplete

removal of the tumor patient developed csf rhinorrhoea on the second post-operative day,

followed by which the patient developed pneumoencephalocoel that manifested as severe

headache, vomiting, and giddiness. The patient was on higher antibiotics, osmotic

86
diuresis, and anti-seizure drugs . The patient was kept in Fowler's position at 30 degrees

and symptoms subsided. This was followed by subsequent surgery to close the defect.

Postoperative period was uneventful. Post-operative diabetes insipidus presented with

polyuria, nocturia, and polydipsia abruptly within the first 24-48 hours of surgery in 4

cases. Thirst was a prominent and constant symptom. The biochemical analysis of post-

operative diabetes insipidus was established by increased osmolarity and hypernatremia

in the presence of hyposmolar urine. Urine-specific gravity was checked every 12 hours,

and urine output was carefully monitored. The fluid replacement was done based on an

input-output chart where input is increased to that of the output loss, and the patient with

manifestation was treated with oral and intranasal desmopressin. All these 4 patients

improved well within a week to 10 days.

One patient who had hypertension as a comorbid condition developed

cerebrovascular accident (CVA) postoperatively due to persistent elevation of blood

pressure leading to anterior cerebral artery infarction. CVA was managed conservatively.

87
 CONCLUSION
In our study, pituitary macroadenoma is predominant in the 5th decade.

Nonsecretory tumors are more than secretory tumors with female preponderance, but

secretory tumors are common in males.

Headache is a common and early symptom with suprasellar extension followed

by visual defects. In sellar tumours the manifestations are less common.

Among secretory macroadenoma, acromegaly is the most common manifestation,

followed by prolactinoma, and the least is ACTH-producing tumor.

MRI is a reasonable tool for predicting the consistency of pituitary

macroadenoma. T2 weighted MRI that is hyperintense without contrast characterizes the

nature of the tumour.

The transsphenoidal endoscopic surgical approach is adequate for the total

removal of pituitary macroadenoma with a cystic and soft consistency. A well-formed

circumscribed capsule confined to sella allows for extracapsular centripetal dissection,

which leads to total resection of macro adenoma.

In solid tumours with extensive suprasellar extension and parasellar encasement

of carotids, the transsphenoidal endoscopic approach may not be adequate for complete

resection.

The incidence of per-operative complications like CSF leak, hemorrhage, and

post-operative diabetes insipidus is very less if a meticulous dissection technique is

carried out with tissue respect and minimal injury.

88
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92
 ANNEXURES

PROFORMA

Serial number MRD NO: IP/OP NUMBER:

Name: Age: Sex:

Address

Occupation Income:

Chief complaints:

History of presenting illness:

1. headache 2. galactorrhoea 3. acromegaly 4. visual defects

5. vomiting 6. cushingoid features 7. impotence 8. loss of libido

8. any history of ear, nose, throat symptoms

Past history: h/o diabetes mellitus, hypertension, TB, Asthma, epilepsy,

h/o irradiation for similar disease, h/o previous surgery

Family history: h/o similar history among family members

Personal history: h/o smoking, alcohol, dietary habits,

CLINICAL EXAMINATION

General examination-consciousness, orientation, built

Pallor, icterus, cyanosis, clubbing, oedema,

Vitals: pulse, blood pressure, temperature, respiratory rate

Anthropometry: height, weight

Systemic examination

1. Central nervous system: level of consciousness

Higher functions

Signs of meningeal irritation

Cranial nerve tests: olfactory, optic, occulomotor, trochlear, trigerminal, abducent,

facial, vestibulocochlear, glossopharyngeal, vagus, cranial spinal accessory and

hypoglossal.

2. Respiratory system

3. Cardiovascular system

4. Gastrointestinal system

Local examination

Ear nose throat examination:

Ear – Right Left

Pinna

Preauricular region

Post auricular region

Tragal tenderness

External auditory canal

Tympanic membrane

Mastoid tenderness

Facial nerve

Fistula sign

Tuning fork test

Rinnie

Weber

ABC

Vestibular and cerebellar function test

Nose: external contour

Anterior nasal examination

Paranasal sinus tenderness

Post nasal examination

Throat

Oral cavity

Oropharynx

Indirect Laryngoscopy

Neck

Investigation:

MRI :
 Size of the tumour:

consistency of tumour- 1. semisolid 2. solid 3. cystic

intensity of the tumour-1. hyperintense 2. hypointense 3. isointense

Extension of tumour - 1. Sellar 2.suprasellar 3.sellar parasellar

4. suprasellar and parasellar

PER OPERATIVE FINDING:

Consistency : 1.soft 2.firm 3.cystic

Extension of tumour :1.similar to MRI findings 2.not similar to

MRI findings

Tumour excision- 1.complete 2.incomplete

Peroperative complication:1.csf leak 2.bleeding 3.damage to

internal carotid artery 4.others 5.no complication

POST OPERATIVE COMPLICATIONS: 1.csf leak 2.diabetes insipidus 3.meningitis

4.pneumoencephalocoel 5.CVA 6. others

7.nil complications

MANAGEMENT OF COMPLICATION: 1. Leak repair 2. desmopressin 3. Antibiotic

4. conservative management of CVA 5. lumbar

drain 6. Others
 INFORMATION SHEET
We are conducting a prospective study on the topic “A study of transsphenoidal endoscopic

excision of pituitary adenomas and their outcomes”

• At Department of ENT along with the Department of Neurosurgery, Madurai Medical

College and Government Rajaji Hospital, Madurai-625020

• The patients' names and identities will be confidential when the results and

suggestions are announced.

• Taking part in this study is voluntary. You are free to decide whether to participate in

this study or to withdraw at any time; your decision will not result in any loss of

benefits to which you are otherwise entitled.

• The results of the special study may be disclosed to you at the end of the study period

or during the study if anything abnormal is found, which may aid in the management

or treatment.

Signature of Investigator Signature of Participant

Date
 PATIENT CONSENT FORM
Title of the Project: A study of transsphenoidal endoscopic excision of pituitary

adenomas and their outcomes

Institution: Madurai Medical College and Government Rajaji Hospital

Madurai-625020

Name : Date :

Age : IP No. :

Sex : Project Patient No. :

The details of the study have been provided to me in writing and explained to me in my own
language.
I confirm that I have understood the above study and had the opportunity to ask questions.
I understood that my participation in the study is voluntary and that I am free to withdraw at
any time, without giving any reason, without the medical care that will normally be provided
by the hospital being affected.
I agree not to restrict the use of any data or results that arise from this study provided such a
use is only for scientific purpose(s).
I have been given an information sheet giving details of the study.
I fully consent to participate in the above study.

________________ _______________ ___________

Name of the subject Signature Date

__________________ _______________ ___________

Name of the Investigator Signature Date
 ABBREVIATIONS
MRI- magnetic resonance imaging

CT- Computed tomography

GH- growth hormone

TSH- thyroid stimulating hormone

ACTH- adenocortico trophic hormone ,

GnRH- gonadotrophic hormone

FSH- follicular stimulating hormone

LH- leutinizing hormone

ADH- anti diuretic hormone

DW MRI- diffusion weighted magnetic resonance imaging

ADC- apparent diffusion coefficient

NSF- naso septal flap

CSF- cerebrospinal fluid

EEEA- extended endoscopic endonasal approach

DI- diabetes insipidus

CVA- Cerebrovascular accidents

ETHICAL COMMITTEE
DIGITAL RECEIPT
 MASTER CHART

RECURRENT/NEW VISUAL CUSHING

SL NO. NAME AGE/SEX HEADACHE PROLACTINOMA ACROMEGALY APOPLEXY
CASES DEFECTS SYNDROME

1 BALAMURUGAN 43/M RECURRENT YES NO NO YES NO NO

2 GUNA 52/M NEW CASE YES NO NO NO NO NO

3 JAYALAKSHMI 58/F RECURRENT YES NO NO YES NO NO

4 JAYARANI 41/F NEW CASE YES NO NO NO NO NO

5 JOTHILAKSHMI 43/F NEW CASE YES NO NO NO NO NO

6 KALPANA 32/F NEW CASE YES YES YES YES NO NO

7 KAMATCHI 51/F NEW CASE YES NO NO NO NO NO

8 LAKSHMI 22/F NEW CASE YES NO NO NO NO NO

9 MANIMEGALI 52/F NEW CASE YES NO NO NO NO YES

10 NAMUNANDI 53/M NEW CASE YES NO NO NO NO NO

11 PANDISELVI 47/F NEW CASE YES NO NO NO NO NO

12 PARIYANNAN 58/M NEW CASE YES NO NO NO NO NO

13 PUSHPAVALLI 50/F NEW CASE YES NO NO NO NO NO

14 RAMALAKSHMI 51/F NEW CASE YES NO NO NO NO NO

15 RAMYA 38/F NEW CASE NO YES YES NO NO NO

16 SAHUL HAMEED 35/M NEW CASE YES NO NO NO NO NO

17 SARAJO 60/F NEW CASE YES NO NO YES NO NO

18 SELVASUTHA 20/F NEW CASE YES NO NO YES NO NO

19 SENTHAMARAI 47/M NEW CASE YES NO NO NO NO NO

20 SUDHA 42/F NEW CASE YES NO NO YES NO NO

21 TAMILARASI 46/F NEW CASE YES NO NO NO NO NO

22 THANGARAJ 46/M NEW CASE YES NO NO NO NO NO

23 VELKUMAR 52/M NEW CASE NO NO NO YES NO NO

24 KATHIJA BEGUM 43/F NEW CASE YES YES YES NO NO YES

25 PERIYASAMMY 27/M NEW CASE YES NO NO NO NO NO

26 BOSE 49/M RECURRENT YES NO NO NO NO NO

27 SELVAM 39/M NEW CASE YES NO NO YES NO NO

28 SEENIYAMMAL 35/F NEW CASE YES NO NO YES NO NO

29 ALAGUPONNU 45/F NEW CASE YES NO NO NO NO NO

30 SUBRAMANIAN 57/M NEW CASE YES NO NO NO NO NO

 MASS TUMOUR CONSISTENCY- TUMOUR INTENSITY-
SL NO. NAME TYPE OF TUMOUR TUMOUR EXTENSION-MRI
EFFECT SIZE(cms) MRI MRI

1 BALAMURUGAN SECRETORY YES 3.2X1.8 SOLID SELLAR&SUPRASELLAR HYPOINTENSE

2 GUNA NON SECRETORY YES 1.7x1.2 SEMISOLID SELLAR HYPERINTENSE

3 JAYALAKSHMI NON SECRETORY YES 1.3x1.5 SEMISOLIDS SELLAR&SUPRASELLAR HYPERINTENSE

4 JAYARANI NON SECRETORY YES 2.8x3.1 SEMISOLID SELLAR HYPERINTENSE

5 JOTHILAKSHMI NON SECRETORY YES 2.8x1.7 SOLID SELLAR&SUPRASELLAR HYPERINTENSE

6 KALPANA SECRETORY YES 2.4x1.5 SEMISOLID SELLAR ISOINTENSE

7 KAMATCHI NON SECRETORY YES 2.8x3.1 SOLID SELLAR&SUPRASELLAR HYPERINTENSE

8 LAKSHMI NON SECRETORY YES 1.7x1.5 SOLID SELLAR&SUPRASELLAR HYPERINTENSE

9 MANIMEGALI SECRETORY YES 3.1x2.4 CYSTIC SELLAR&SUPRASELLAR HYPOINTENSE

10 NAMUNANDI NON SECRETORY YES 1.1x1.4 SOLID SELLAR&SUPRASELLAR HYPOINTENSE

11 PANDISELVI NON SECRETORY YES 2.2x2.1 SOLID SELLAR&SUPRASELLAR ISOINTENSE

12 PARIYANNAN NON SECRETORY YES 3.5x2.7 SEMISOLID SELLAR&SUPRASELLAR HYPERINTENSE

13 PUSHPAVALLI NON SECRETORY YES 1.2x1.3 SEMISOLID SELLAR&SUPRASELLAR HYPERINTENSE

14 RAMALAKSHMI NON SECRETORY YES 2.7x2.4 SEMISOLID SELLAR&SUPRASELLAR HYPERINTENSE

15 RAMYA SECRETORY YES 1.7x1.5 CYSTIC SELLAR&SUPRASELLAR ISOINTENSE

16 SAHUL HAMEED NON SECRETORY YES 1.9x2.0 SOLID SELLAR&SUPRASELLAR ISOINTENSE

17 SARAJO SECRETORY YES 2.9x2.7 SOLID SELLAR&SUPRASELLAR HYPOINTENSE

18 SELVASUTHA SECRETORY YES 2.5x2.1 SOLID SELLAR&SUPRASELLAR ISOINTENSE

19 SENTHAMARAI NON SECRETORY YES 1.1x1.5 CYSTIC SELLAR,SUPRASELLAR&PARASELLAR HYPOINTENSE

20 SUDHA SECRETORY YES 1.7x1.4 SOLID SELLAR,SUPRASELLAR&PARASELLAR ISOINTENSE

21 TAMILARASI NON SECRETORY YES 1.3x1.2 SOLID SELLAR&SUPRASELLAR ISOINTENSE

22 THANGARAJ NON SECRETORY YES 2.2x2.3 SEMISOLID SELLAR&SUPRASELLAR ISOTENSE

23 VELKUMAR NON SECRETORY YES 1.2x1.2 SOLID SELLAR&SUPRASELLAR HYPOINTENSE

24 KATHIJA BEGUM SECRETORY YES 2.2x1.9 SOLID SELLAR,SUPRASELLAR&PARASELLAR HYPERINTENSE

25 PERIYASAMMY NON SECRETORY YES 1.6x1.8 SOLID SELLAR&PARASELLAR HYPERINTENSE

26 BOSE NON SECRETORY YES 1.7x2.3 SEMISOLID SELLAR ISOINTENSE

27 SELVAM SECRETORY YES 1.5x1.4 SOLID SELLAR ISOINTENSE

28 SEENIYAMMAL SECRETORY YES 2.4x2.1 SEMISOLID SELLAR HYPOINTENSE

29 ALAGUPONNU NON SECRETORY YES 1.5x1.8 CYSTIC SELLAR HYPOINTENSE

30 SUBRAMANIAN NON SECRETORY YES 3.1x2.6 SOLID SELLAR ISOINTENSE

 TUMOUR
TUMOUR CONSISTENCY
SL EXTENSION- TUMOUR PEROPERATIVE
NAME INTENSITY- PER
NO. PER EXCISION COMPLICATIONS
MRI OPERATIVE
OPERATIVE

1 BALAMURUGAN HYPOINTENSE SOLID SIMILAR INCOMPLETE NIL

2 GUNA HYPERINTENSE SEMISOLID SIMILAR COMPLETE NIL

3 JAYALAKSHMI HYPERINTENSE SEMISOLID SIMILAR COMPLETE NIL

4 JAYARANI HYPERINTENSE SEMISOLID SIMILAR COMPLETE NIL

5 JOTHILAKSHMI HYPERINTENSE SOLID SIMILAR COMPLETE NIL

6 KALPANA ISOINTENSE SEMISOLID SIMILAR COMPLETE NIL

7 KAMATCHI HYPERINTENSE SOLID SIMILAR COMPLETE NIL

8 LAKSHMI HYPERINTENSE SOLID SIMILAR COMPLETE NIL

9 MANIMEGALI HYPOINTENSE CYSTIC SIMILAR COMPLETE NIL

10 NAMUNANDI HYPOINTENSE SOLID SIMILAR COMPLETE NIL

11 PANDISELVI ISOINTENSE SOLID SIMILAR COMPLETE NIL

12 PARIYANNAN HYPERINTENSE SEMISOLID SIMILAR COMPLETE NIL

13 PUSHPAVALLI HYPERINTENSE SEMISOLID SIMILAR COMPLETE NIL

14 RAMALAKSHMI HYPERINTENSE SEMISOLID SIMILAR COMPLETE NIL

15 RAMYA ISOINTENSE CYSTIC SIMILAR COMPLETE NIL

16 SAHUL HAMEED ISOINTENSE SOLID SIMILAR COMPLETE NIL

17 SARAJO HYPOINTENSE SOLID SIMILAR COMPLETE NIL

18 SELVASUTHA ISOINTENSE SOLID SIMILAR COMPLETE NIL

19 SENTHAMARAI HYPOINTENSE CYSTIC SIMILAR INCOMPLETE NIL

20 SUDHA ISOINTENSE SOLID SIMILAR INCOMPLETE NIL

21 TAMILARASI ISOINTENSE SOLID SIMILAR COMPLETE NIL

22 THANGARAJ ISOTENSE SEMISOLID SIMILAR COMPLETE NIL

23 VELKUMAR HYPOINTENSE SOLID SIMILAR COMPLETE NIL

KATHIJA
24 HYPERINTENSE SOLID SIMILAR INCOMPLETE CSF LEAK
BEGUM
25 PERIYASAMMY HYPERINTENSE SOLID SIMILAR INCOMPLETE CSF LEAK

26 BOSE ISOINTENSE SEMISOLID SIMILAR INCOMPLETE NIL

27 SELVAM ISOINTENSE SOLID SIMILAR COMPLETE NIL

28 SEENIYAMMAL HYPOINTENSE SEMISOLID SIMILAR COMPLETE NIL

29 ALAGUPONNU HYPOINTENSE CYSTIC SIMILAR COMPLETE CSF LEAK

30 SUBRAMANIAN ISOINTENSE SOLID SIMILAR COMPLETE NIL

 POST OPERATIVE COMPLICATIONS
SL MANAGEMENT OF
NAME
NO. CSF DIABETES COMPLICATIONS
PNEUMOENCEPHALOCOEL CVA
LEAK INSIPIDUS
1 BALAMURUGAN NO NO NO NO NA

2 GUNA NO NO NO NO NA

3 JAYALAKSHMI NO NO NO NO NA

4 JAYARANI NO NO NO NO NA

5 JOTHILAKSHMI NO NO NO NO NA

6 KALPANA NO NO NO NO NA

7 KAMATCHI NO NO NO NO NA

8 LAKSHMI NO NO NO NO NA

9 MANIMEGALI NO NO NO NO NA

10 NAMUNANDI NO NO NO NO NA

11 PANDISELVI NO NO NO NO NA

12 PARIYANNAN NO NO NO NO NA

13 PUSHPAVALLI NO NO NO NO NA

14 RAMALAKSHMI NO NO NO NO NA

15 RAMYA NO NO NO NO NA

16 SAHUL HAMEED NO NO NO NO NA

17 SARAJO NO NO NO NO NA
18 SELVASUTHA NO NO NO NO NA

19 SENTHAMARAI NO NO NO NO NA

20 SUDHA NO YES NO NO DESMOPRESSIN

CVA CONSERVATIVE
21 TAMILARASI NO NO NO YES
MANAGEMENT
22 THANGARAJ NO NO NO NO NA
DESMOPRESSIN, CVA
23 VELKUMAR NO YES NO YES
CONSERVATIVE MANAGEMENT
DESMOPRESSIN, CONSERVATIVE
24 KATHIJA BEGUM YES YES NO NO
MANAGEMENT
DESMOPRESSIN, CONSERVATIVE
25 PERIYASAMMY YES YES NO NO
MANAGEMENT
26 BOSE NO NO NO NO NA

27 SELVAM NO NO NO NO NA

28 SEENIYAMMAL NO NO NO NO NA

29 ALAGUPONNU YES NO NO NO DESMOPRESSIN

30 SUBRAMANIAN NO NO NO NO NA