The Direct Microscopic Transnasal Approach in the Removal of Sellar Lesions

Purpose: The transnasal transphenodal approach is the procedure of choice for pituitary adenomas and other sellar tumors. A pure endoscopic approach avoids the complications of septal manipulations but does not replace traditional microsurgery. The direct transnasal approach allows a rapid opening of the sella, without any anterior nasal mucosa dissection, good vision under the microscope, and the eventual insertion of the endoscope.

Method: Between July 2004 and June 2006, 40 patients were operated upon via the direct transnasal approach. Thirty-six had pituitary adenoma, 1 had chordoma, 1 tuberculum sellae meningioma, 1 Rathke's cleft cyst, and 1 had dermoid. Adenomas were 27 macro, 6 micro, 2 giant, and 1 invasive. Twenty-three were nonsecreting, and 8 were GH-, 4 PRL-, and 1 ACTH-producing. The speculum was inserted deeply in one nostril, and, under the microscope, a small incision was done on the mucosa where the bone septum reached the vomer. At that point, the septum was luxated contralaterally, the speculum advanced on the midline, the sphenoidal sinus opened, and the sella identified. This part of the operation lasted from 10 to 20 minutes. The rest of the operation was done as usual. The endoscope was inserted in all macroadenomas to detect eventual remnants of the tumor and to explore the sellar diaphragma. In the nonadenoma patients it was used also to remove the lesion. In 13 cases it allowed the visualization of neoplastic remnants that were hidden with the microscope. Nasal packing was was done routinely for 12 to 24 hours.

Result: No specific complications due to the technique were observed. Comparing the immediate satisfaction of the patients (the degree of complaint for local distress due to the approach) with the historical experience in our hands, the results are excellent. At 3 months there were no complaints of any nasal disturbances (about 10% in the historical series). From oncological and endocrinological points of view the results were as good as usual. The insertion of the endoscope, particularly the one at 30 degrees, is very useful in detecting tumor remnants in macro- and giant adenomas as well as in the nonadenomatous cases.

Conclusion: We think that the combined use of this approach with the use of the endoscope is a real advancement in pituitary surgery if compared either with the traditional sublabial or the anterior transeptal submucosal approaches.