Endoscopic Pituitary Surgery

Endoscopic Pituitary Tumor Surgery at

University of California Irvine Medical Center

The pituitary gland is located approximately 3-4 inches behind the top of one’s nostril. The pituitary gland is a gland that produces multiple different hormones that are important in the function of the body. Occasionally the cells that produce the various tumors can grow without control and produce a tumor. Tumors of the pituitary gland are generally benign, i.e., they do not spread to the rest of the body, but due to the hormones they produce, can create multiple functional problems.

Presentation of Pituitary Tumors

Cushing’s Syndrome:

The tumors that over-produce the hormone that stimulates cortisol (steroid hormone) causes Cushing’s disease.

This disease presents with:

• Weight gain, especially in the face
• Rounded face appearance
• Development of a hump behind the neck
• Purple stretch marks, easy bruising
• Muscle weakness
• Head aches
• Visual Problems

Acromegaly or Gigantism:

The tumors that over-produce growth hormone, the hormone that stimulates growth can lead to many problems.

If the tumor presents in a patient younger than 18 years of age, the tumor leads to gigantism.

In patients over the age of 18 years, it leads to acromegaly.

Acromegaly symptoms include:

• The first symptoms commonly are headaches and problems with vision
• Puffiness and enlargment of hands, feet, ears and nose
• Increased body hair
• Hard and thickened nails
• Coarsening of facial features
• Swollen eyelids
• Fatigue
• Back and joint pain
• Change in glove and shoe sizes

Gigantism symptoms include:

• Sudden increase in growth

• Enlarging head
• Exaggerated growth of the hands and feet
• Coarsening of facial features
• Excessive sweating

Tumors that produce the hormone prolactin (the hormone that stimulates breast gland growth and milk production) can present with:

• Women in the reproductive years can present with changes in menstruation or infertility. 
• The menstrual cycle changes are most commonly, infrequent periods, no periods, or irregular cycles.
• Galactorrhea, or milk production
• Decreased estrogen leading to vaginal dryness
• In men, prolactinoma can lead to the shrinking of testicles, which can lead to decreased libido, erectile dysfunction, or infertility
• Men can also develop milk production from the breasts
• Head ache and visual loss can occur with any pituitary tumor

Examples of Pituitary tumors (the white ball-like mass in the middle of each picture) treated with the endoscopic approach.

Surgical Treatment

In the past, pituitary tumors were removed using approaches either through the nose or by making large incisions under the lip and connecting it into the nose. Then a large retractor would be placed into the nose to keep it wide open for the surgery to be performed with a microscope. These older approaches have the side effect of causing cosmetic change in the appearance in the nose or leading to difficulties in breathing through the nose. The scarring that develops under the lip can cause difficulties with eating, etc.

Currently the cutting edge in the approach to the pituitary gland is the endoscopic approach. Instead of the large incisions or the approaches through the nose, a 4 mm (1/6th of an inch) endoscope is used through the nose to open the sphenoid sinus (the sinus which is situated anterior to the pituitary gland). A computer is used for tracking the location of the instruments and to allow the surgeon with the extra margin of safety that is needed in locating and opening of the sphenoid sinus.

Instruments are used through both nostrils and the tumor is removed under the magnified view of the endoscope. The surgery generally takes 1-2 hours (versus 3-4 hours with the older approaches). The patient has significantly less pain and discomfort. Most patients will go home in the next couple of days. This approach also avoids the placement of the Mayfield head-holder (the pins placed in the head to keep the head position constant) and the intra-operative x-rays and radiation that was required in the past with the older approaches.

Advantages of the Endoscopic Approach compared to the traditional approaches:

• Elimination of the cosmetic problems
• No incisions on the nose or under the lip
• Minimal pain or discomfort post-operatively
• No need for placement of the head holder pins in the head
• Significantly shorter procedure duration
• No need for a large retractor placed in the nose
• Reduced likelihood of scarring in nose
• No radiation intra-operatively
• The ability to place an angled endoscope within the tumor cavity and to see areas behind ledges not always possible with the traditional approaches with a microscope

The endoscopic skull base surgeon works with the neurosurgeons at the UCI Medical Center in the removal of pituitary tumors using the endoscopic approach. The minimally invasive approach and resection is done with the two surgeons working side by side.

New Innovations in the Treatment of Skull Base Tumors

The Team Approach to the treatment of skull base tumors has become the best approach in the treatment of these complex disorders. The team involves a head and neck skull base surgeon (neurotologist or anterior skull base surgeon) and a skull base neurosurgeon. The combination of the two specialties allows for the best care for the patients. The Skull Base Surgery Team at UC Irvine discusses the plan of treatment for the patients and plans for the best option for each particular patient. The team also reviews imaging studies for patients from outside of Southern California before their visit and accommodates these patients to give them the best possible and most efficient care.

Computer-assisted Navigation

Computer-assisted imaging navigation has allowed for better identification and preservation of sensitive structures during surgery of skull base tumors. Using this technology, the surgeons can visualize on the screen in 3 dimensions where a particular tumor and its surrounding structures are located while performing the surgery to reduce the chance of complications. Computer-assisted image guidance navigation is a routine part of the skull base team's.

Intra-operative MRI

Another area of cutting edge technology available at the UC Irvine Skull Base Program is the use of imaging during the surgery to insure that the entire tumor has been removed. The special intra-operative MRI suite allows the skull base surgeons to obtain an MRI during the surgery to see if the entire tumor has been removed.

To make an appointment, please call 714-456-7017 or click here to request an appointment via the web.