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J Neurosurg 2018 Jun 1:1-7. Epub 2018 Jun 1.

2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Clival lesions are still considered surgically complex due to their anatomical location. Critical structures, such as the internal carotid arteries (ICAs), cavernous sinuses, cranial nerves, and brainstem, may be encased within the lesion. Although advances in endoscopic endonasal approaches have provided new routes to these lesions, exposure and resection of clival tumors through the endonasal route remain a technical challenge. Read More

Acta Neurochir (Wien) 2017 07 12;159(7):1247-1252. Epub 2017 May 12.

Department of otorhinolaryngology-skull base surgery, Neuroscience hospital, Baghdad, Iraq.

Background: There are multiple approaches to reach the sellar region using microscope or endoscope, which are the old sublabial, with its post-operative morbidities, or the uni-nostril transseptal, which has a limited working field. Another technique is the direct transnasal, which is associated with tissue sacrifice, and lastly the bi-nostril (one side transseptal-other side transnasal), aiming to preserve one of the septal flaps.

Method: We have 27 case studies using a new technique in which we access the sphenoid endoscopicaly through the nasal septum from both nostrils under the mucoperichondrial-periosteal flap. Read More

J Neurosurg 2016 08 11;125(2):323-33. Epub 2015 Dec 11.

Departments of 1 Neurosurgery and.

OBJECT Both endoscopic and microscopic transsphenoidal approaches are accepted techniques for the resection of pituitary adenomas. Although studies have explored patient outcomes for each technique individually, none have prospectively compared sinonasal and quality of life outcomes in a concurrent series of patients at the same institution, as has been done in the present study. METHODS Patients with nonfunctioning adenomas undergoing transsphenoidal surgery were assessed for sinonasal function, quality of life, and pain using the Sino-Nasal Outcome Test-20 (SNOT-20), the short form of the Nasal Obstruction Symptom Evaluation (NOSE) instrument, the SF-36, and a headache scale. Read More

Neurosurgery 2015 Mar;11 Suppl 2:69-78; discussion 78-9

*Division of Neurological Surgery and ‡Division of Neurosurgery Research, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Background: Microscopic and endoscopic transsphenoidal approaches to the sellar are well established. Surgical freedom is an important skull base principle that can be measured objectively and used to compare approaches.

Objective: To compare the surgical freedom of 4 transsphenoidal approaches to the sella turcica to aid in surgical approach selection. Read More

Clin Neurol Neurosurg 2013 Sep 13;115(9):1632-4. Epub 2013 Mar 13.

Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, United States.

Objective: The transsphenoidal approach to the pathology of sellar region is a fundamental procedure in the armamentarium of neurosurgeons. Modern practice tends to prefer various transnasal approaches over the more traditional sublabial route. However, the transnasal approach can be limited by small nares, particularly in the pediatric population. Read More

Int Forum Allergy Rhinol 2011 Jul-Aug;1(4):242-9. Epub 2011 Apr 28.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA.

Background: Two surgical approaches to the pituitary are commonly used: the sublabial-transseptal (SLTS) approach using microscopy and the endonasal endoscopic minimally invasive (MIPS) approach. Although outcomes are similar for both procedures, MIPS has become increasingly prevalent over the last 15 years. Limited cost analysis data comparing the 2 alternatives are available. Read More

J Neurosurg 2011 May 7;114(5):1380-5. Epub 2011 Jan 7.

Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri, USA.

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. Read More

Acta Otorrinolaringol Esp 2011 Jan-Feb;62(1):25-30. Epub 2010 Nov 26.

Sección de Rinología, Servicio de Otorrinolaringología, Hospital General Univesitario, Universitat de València, Valencia, España.

Background: The surgical approach to the pituitary fossae has evolved from transcranial to sublabial and transseptal microscopic ones, up to the current transsphenoidal endoscopic approach.

Objectives: To present our experience in the transnasal transsphenoidal approach for pituitary adenomas and the modifications introduced to improve tumoral resection and to lower iatrogenia.

Material And Methods: Over nine years, we operated on 37 patients with pituitary adenomas using the transsphenoidal endoscopic approach. Read More

Clin Anat 2010 Sep;23(6):629-36

Department of Anatomy, Medical School, Aristotle University of Thessaloniki, Greece.

A study of 24 adult Caucasian cadavers was undertaken to assess and document the anatomical measurements within the nasal cavity and sphenoid sinus as routes of instrumentation utilized in sublabial transsphenoidal and endonasal endoscopic approaches. Five measurements were performed. The mean thickness of the anterior sellar wall was 0. Read More

Neurochirurgie 2010 Apr-Jun;56(2-3):230-5. Epub 2010 Mar 27.

Service de neurochirurgie, CHU de Hautepierre, Hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.

During the last decade, the use of endoscopic endonasal approaches to the pituitary has increased considerably. The endoscopic endonasal and transantral approaches offer a minimally invasive alternative to the classic transcranial or transconjunctival approaches to the medial aspect of the orbit. The medial wall of the orbit, the orbital apex, and the optic canal can be exposed through a middle meatal antrostomy, an anterior and posterior ethmoidectomy, and a sphenoidotomy. Read More

Braz J Otorhinolaryngol 2009 May-Jun;75(3):345-9

Centro de Neuroendocrinologia, Santa Casa de Porto Alegre, UFCSPA.

Unlabelled: Transsphenoidal surgery is the most commonly used surgical procedure to handle the hypophyseal region, sometimes associated with oronasal complications.

Material And Methods/aim: To evaluate prospectively (specific questionnaire, clinical evaluation) undiagnosed chronic oronasal complications in patients submitted to conventional transsphenoidal adenomectomy surgery, operated at different neurosurgery services more than 6 months ago.

Results: 49 patients were evaluated, 37/45 presented macroadenoma. Read More

J Oral Maxillofac Surg 2009 May;67(5):1052-7

Division of Oral and Maxillofacial Surgery, Department of Neurosurgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-9109, USA.

Purpose: The purpose of this study is to compare the access afforded by the Le Fort I osteotomy with the more traditional sublabial and endonasal approaches to the pituitary fossa.

Patients And Methods: Five fresh cadaveric heads were obtained for this study. Endonasal, sublabial, and Le Fort I osteotomy approaches to the pituitary fossa were performed on each specimen. Read More

Turk Neurosurg 2008 Oct;18(4):425-30

Diskapi Yildirim Bayezit Egitim ve Arastirma Hastanesi, 2. Norosirurji Klinigi, Ankara, Turkey.

Objective: The aim of this presentation is to show that the sublabial transseptal transsphenoidal approach to pituitary adenomas is the least invasive anatomic route with the lowest postoperative complication rates.

Patients And Method: This study was based on a retrospective analysis of 276 patients with a diagnosis of pituitary adenoma who were surgically treated via the sublabial transsphenoidal route.

Results: The overall complication rate of the presented series was 14. Read More

Auris Nasus Larynx 2009 Aug 20;36(4):411-5. Epub 2008 Nov 20.

Department of Otolaryngology, Takanoko Hospital, 525-1 Takanoko-cho, Matsuyama, Ehime 790-0925, Japan.

Objective: Surgery for localized sphenoid sinus disease can be performed in different ways. Direct (transnasal) and indirect (transethmoidal) approaches are now prevalent in endoscopic endonasal sinus surgery (ESS) because they are safe and effective. However, the identification or treatment of a sinus is occasionally difficult due to the anatomical variation, postoperative changes, or other reasons. Read More

J Neurosurg 2008 Nov;109(5):783-93

Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Object: Midline clival lesions, whether involving the clivus or simply situated anterior to the brainstem, present a technical challenge for adequate exposure and safe resection. The authors describe, as a minimally invasive technique, an anterior clivectomy performed via an expanded transsphenoidal approach coupled with the use of a neuronavigation on mobile head and endoscopic-assisted technique. Wide and direct exposure, with the ability to resect extra- and intradural tumors, was achieved without mortality and with a low rate of complications. Read More

Acta Neurochir (Wien) 2008 Nov 29;150(11):1133-8; discussion 1138-9. Epub 2008 Oct 29.

Department of Neurosurgery, School of Medicine, (GATA), Gulhane Military Medical Academy (GATA)TR-06018 Etlik, Ankara, Turkey.

Background: Evolving of a single centre by means of different transsphenoidal approaches during the survey of methodological advances in pituitary surgery is presented.

Materials And Methods: Ninety-three consecutive patients with pituitary adenomas underwent transphenoidal pituitary operations at Gulhane Military Medical Academy from January 1996 to October 2007. Retrospective chart-based analysis of the surgical methods of transsphenoidal pituitary adenoma operations were done. Read More

Am J Rhinol 2007 Mar-Apr;21(2):203-6

Departments of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Background: The aim of this study was to compare three different techniques for transsphenoidal pituitary surgery: (1) sublabial transseptal approach with microscopic resection, (2) transnasal transseptal approach with endoscopic resection, and (3) endoscopic approach with endoscopic resection.

Methods: We performed a retrospective review of 50 pituitary surgeries performed by the same neurosurgeon. Demographic, radiographic, and clinical data were collected. Read More

J Neurosurg 2007 Mar;106(3):400-6

Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York 10021, USA.

Object: The extended transsphenoidal approach is a less invasive method for removing purely suprasellar lesions compared with traditional transcranial approaches. Most advocates have used a sublabial incision and a microscope and have reported a significant risk of cerebrospinal fluid (CSF) leakage. The authors report on a series of purely endoscopic endonasal surgeries for resection of suprasellar supradiaphragmatic lesions above a normal-sized sella turcica with a low risk of CSF leakage. Read More

J Clin Neurosci 2007 Mar;14(3):267-72

Department of Neurological Surgery, Wakayama Medical University, 811-1 Kimiidera Wakayama, 641-0012 Japan.

A variety of surgical approaches have been used in the treatment of midline cranial base tumors. These approaches usually involve complicated techniques, particularly when they are employed for tumors involving the entire clivus. This paper describes the feasibility, efficacy, and safety of the sublabial transnasal approach combined with a partial resection of the nasal floor in the treatment of midline skull base lesions. Read More

Surg Neurol 2006 Apr;65(4):332-41, discussion 341-2

Division of Neurosurgery, University of California at Los Angeles School of Medicine, 200 UCLA Medical Plaza, Los Angeles, CA 90095-7182, USA.

Background: Patient impressions remain an important yet often overlooked aspect of surgical success. Herein we present postoperative questionnaire results in patients after a standard direct endonasal approach, an extended suprasellar endonasal approach, and a reoperative transsphenoidal surgery for tumor removal with the operating microscope.

Methods: From July 1998 through April 2005, of 452 patients undergoing endonasal surgery, 346 were sent questionnaires, and of these, 259 (75%) completed them. Read More

J Neurosurg 2005 Dec;103(6):1096-104

Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City 84132, USA.

The transnasal transsphenoidal approach is the preferred route for removal of most lesions of the sella turcica. The concept of transnasal surgery traversing the sphenoid sinus to reach the sella has existed for nearly a century. A comprehensive historical overview of the evolution of transsphenoidal surgery has been reported previously. Read More

Minim Invasive Neurosurg 2005 Feb;48(1):19-24

University of Nebraska Medical Center Omaha, NE 68198-2035, USA.

Object: The aim of the study was to perform endoscopic anatomical studies of skull base structures through the sphenoid sinus in order to better understand endoscopic approaches to skull base lesions.

Methods: Anatomical studies were performed on six cadavers using sinus endoscopes. The sphenoid sinus was entered via a sublabial nasoseptal approach. Read More

Laryngoscope 2004 Nov;114(11):1945-8

Department of Otolaryngology--Head and Neck Surgery, University of North Carolina Hospitals, Chapel Hill, NC 27599-7070, USA.

Introduction: Transsphenoidal hypophysectomy is becoming progressively less invasive. Recent endoscopic techniques avoid nasal or intraoral incisions, use of nasal speculums, and nasal packing. Several case series of endoscopic endonasal pituitary surgery have been reported, but relatively little data exists comparing complication rates to more traditional approaches. Read More

Rozhl Chir 2003 Sep;82(9):452-5

Neurochirurgická klinika 1. LF UK a UVN, Praha.

Currently there are three major surgical approaches into the sphenoid sinus during transsphenoidal microsurgery. The first approach is the sublabial incision with submucous resection along the nasal septum. It is particularly advantageous in patients with small nasal apertures, in pediatric patients, and for large tumors extending into the cavernous sinuses or into the clivus. Read More

Acta Otorrinolaringol Esp 2003 Jun-Jul;54(6):419-24

Servicio de Otorrinolaringología, Hospital General Universitario, Facultad de Medicina, Valencia.

Transsphenoidal approach is the most commonly employed surgical technique for the resection of pituitary tumors. We present our experience in the transnasal-transsphenoidal approach in 30 patients undergoing pituitary surgery from 1998 to 2002. Ten patients underwent surgery via a sublabial-transeptal-transsphenoidal approach, 15 patients via a transeptal-transsphenoidal approach and 5 patients via a pure endoscopic transnasal-transsphenoidal. Read More

Biomed Pharmacother 2002 ;56 Suppl 1:165s-170s

Department of Neurosurgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, Japan.

The history of the transsphenoidal approach for pituitary surgery is reviewed in this mini review. There are several approaches to the sphenoid sinus, and the sublabial transseptal and transnasal transseptal approaches are presently the most widely accepted standard techniques. Although the transnasal approach has several advantages in comparison with the sublabial approach, it is difficult to accomplish in the small nostril without an alotomy incision or external rhinoplasty incision, which may lead to noticeable scarring or nasal deformity. Read More

Am J Rhinol 2001 Nov-Dec;15(6):377-9

Department of Otolaryngology, State University of New York, Health Science Center at Brooklyn, USA.

The endoscopic transnasal approach is gaining increasing popularity as the surgical method of choice for treatment of pituitary lesions. Previous studies have shown advantages such as quicker recovery and fewer cosmetic, dental, and nasal complications. However, no study has compared the rate of diabetes insipidus (DI) between the traditional and endoscopic approaches. Read More

Pituitary 1999 Aug;2(2):139-54

Department of Neurological Surgery, University of Pittsburgh School of Medicine, PA 15213, USA.

Endoscopy has been adopted for transsphenoidal pituitary surgery. A rigid rod-lens endoscope, 4-mm in diameter and 18 cm in length, is used in replacement of the operating microscope. This endoscopic technique utilizes the patient's natural nasal air passage as a surgical corridor without a sublabial or nasal mucosal incision. Read More

Surg Neurol 2000 Feb;53(2):168-72; discussion 172-3

Department of Neurological Surgery, University of Wisconsin School of Medicine, Madison 53792-3232, USA.

Background: Submucosal dissection of the nasal septum is often performed as part of the transseptal approach to the sella. To evaluate whether this submucosal dissection is a necessary component of this operation, we compared the morbidity of a direct transmucosal endonasal approach to that of the transseptal approach in patients undergoing pituitary surgery.

Methods: Forty-one consecutive patients undergoing pituitary surgery from January 1996 to March 1999 were included in this study. Read More

Otolaryngol Head Neck Surg 2000 Mar;122(3):367-9

Departments of Otolaryngology-Head and Neck Surgery and Neurological Surgery, New York Medical College, NY, USA.

Tumors of the hypophysis are often managed surgically by the neurosurgeon and the otolaryngologist. Three widely used anterior routes to the sella are the endonasal (transcolumellar) transsphenoidal, sublabial transsphenoidal, and transethmoidal approaches. We reviewed the charts of 60 patients who underwent surgery, 42 transcolumellar and 18 sublabial, for sellar and parasellar adenomas and compared the two transsphenoidal approaches. Read More

Otolaryngol Head Neck Surg 1999 Jun;120(6):824-7

Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, USA.

Increasingly, the otolaryngologist is called on to provide exposure for the neurosurgeon performing transsphenoidal hypophysectomy. The 3 most common approaches for this exposure are the transnasal transseptal, sublabial transseptal, and external rhinoplasty approaches. We reviewed our series of 135 patients undergoing transnasal hypophysectomy for postoperative complications. Read More

Otolaryngol Head Neck Surg 1998 Feb;118(2):191-4

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2559, USA.

Objective: Advances in imaging resolution have resulted in superior visualization of intracranial anatomy. Because of the inherent complexity of the surgical exposure of these lesions, intraoperative localizing techniques are required. Currently, C-arm fluoroscopy provides only two-dimensional localization for these anatomic structures. Read More

Neurosurgery 1997 May;40(5):944-6

Department of Otolaryngology, Rabin Medical Center, Petah Tiqva, Israel.

Objective: Transseptal transsphenoidal surgery of pituitary tumors is a well-established surgical technique. The sublabial approach and the open rhinoplasty approach are most commonly used. In both cases, the surgical avenue is along the entire length of the nasal septum, removing both nasal cartilage and the vomer. Read More

Otolaryngol Head Neck Surg 1996 Jul;115(1):64-9

Department of Otolaryngology/Head and Neck Surgery, Marshfield Clinic, WI 54449, USA.

Transseptal transsphenoidal approach to the pituitary fossa is a well-described and effective procedure. This article relates our experience with this procedure with specific emphasis on the nasal septum, both before and after surgery. It has been our experience that this surgery has minimal local complications in the nose and it would appear to improve septal alignment with subjective improvement in nasal function as reported by the patient. Read More

Laryngoscope 1990 Aug;100(8):817-9

Division of Otolaryngology, George Washington University Medical Center, Washington, DC 20037.

Our experience with over 147 operations for pituitary disease has given us an opportunity to use and evaluate four separate transseptal approaches. Three approaches have been described previously in the literature: the sublabial transseptal, the open rhinoplasty, and the alotomy with anterior septal dissection. The fourth approach, alotomy with posterior septal dissection, is described here. Read More

Laryngoscope 1988 Dec;98(12):1301-8

Department of Otolaryngology--Head and Neck Surgery, University of Washington, Seattle.

Multiple surgical approaches to the sella turcica have been described. The sublabial transseptal transsphenoidal approach provides a safe, cosmetically acceptable route to the sella with excellent exposure. Since 1976, we have employed this technique for the surgical treatment of pituitary neoplasms and parasellar tumors. Read More

Clin Obstet Gynecol 1980 Jun;23(2):413-23

Present methods of pituitary surgery had their inception in the late 1890s. The methods of Halsted, Cushing, and Hirsch of the early 1900s have been developed and refined for continued use today. The advent of the operating microscope and microsurgical operative techniques stimulated a renaissance of interest in transsphenoidal methods for resecting pituitary tumors. Read More