What does surgery through the nose for pituitary tumors involve?

Anthony P. Heaney, MD
Endocrinology Diabetes & Metabolism
Surgery through the nose for pituitary tumors is a natural and relatively non-destructive approach, as the pituitary gland lies behind the eyes and central in the skull. Most centers use an endoscopic approach which allows direct visualization of the surgical procedure as it happens. The approach involves removing some tissue and bone at the back of the nose, then passing through the sphenoid sinus (which is like a cave behind the nose) before removing the bone that forms the floor where the pituitary gland sits. This enables the pituitary tumor to be carefully removed directly which significantly reduces complications of this procedure. In most cases, hospital admission is one day and the site of surgery is not visible given the scar is far back behind the nose.
Marvin Bergsneider, MD
In traditional surgery to remove a pituitary tumor, surgeons put a speculum down the nose. They have a very small area to work in, so they don't see all that they need to see. Although it can be effective for smaller tumors and some other tumors, almost every pituitary surgeon now uses an endoscopic view. An endoscopic view allows doctors to see all the structures of the nose. With endoscopic surgery, experienced surgeons can literally just peel the tumor off the normal gland, thus preserving the function of the normal gland, because they can basically see everything.

There's increasing consensus that endoscopic surgery is safer. It allows more complete removal of even larger tumors. Many tumors that previously were considered inoperable, either through the nose or in some cases just plain inoperable, are now routinely approached with endoscopic surgery.
The two main surgical techniques for removing pituitary tumors are transnasal transphenoidal adenomectomy and transcranial adenomectomy. The transnasal transphenoidal is the preferred surgical management for the majority of pituitary tumors. The tumor is removed via the nose and sinuses with no external incision. If the tumor has invaded nearby nerves, brain tissue and/or surrounding structures, or if it is large, removal by transphenoidal may prove difficult. Thus, the neurosurgeon may choose to perform a transcranial hypophysectomy in which the more complicated tumor is removed through the upper part of the skull by way of an incision in the patient's scalp. At times, a combination of surgical approaches is employed.

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