The rhinologist and the management of pituitary disease

Since the early days of pituitary surgery, a variety of transnasal approaches have been used to gain access to the sella turcica. Each of these approaches requires crossing the sphenoid sinus, hence the transsphenoidalnoidal designation of these methods. Since the growth and refinement of microsurgery as a distinct surgical discipline, there has been a coincidental maturation of transsphenoidal microsurgical techniques for the management of a variety of pituitary disorders. The present paper reviews the historical events leading to the current methods of transphenoidal pituitary surgery. Detailed descriptions of each method are given, with the advantages and disadvantages of each. The author's method is described and illustrated in a step-by-step manner, and the criteria which determine operability by transsphenoidal versus transfrontal craniotomy are discussed. The advantages which transsphenoidal techniques offer over transfrontal methods are emphasized. The paper deals with pituitary disorders on a clinical and pathological basis. The work-up of pituitary lesions is discussed, with a detailed presentation of the endocrine evaluation. Further emphasis is given to the value of tomography of the sphenosellar complex in planning operative approaches for removal of pituitary lesions, particularly when the lesion is a so-called "microadenoma," producing no obvious expansion nor erosion of the cellar floor. The author's experience in the management of 125 lesions of the pituitary or associated sella turcica is presented and complications are discussed. Because of the relatively brief period of follow-up, no conclusive evidence can be offered regarding cures in the author's series. However, on the basis of reported experience by others working in the same area, one may expect acceptable long-term improvement or cures in selected pituitary lesions operated on by transshpenoidal methods. The team management of pituitary disorders is stressed. In particular, emphasis is given to the contributions which the current day otorhinolaryngologist can make, because of his knowledge and experience in rhinological and microsurgical techniques. There is no other surgical specialty so uniquely qualified to provide operative treatment of pituitary lesions using transsphenoidal surgical pathways.