Quality of life outcomes after transnasal endoscopic pituitary surgery using the Glasgow Benefit Inventory.

PURPOSE: This study assesses postoperative quality-of-life outcomes via the Glasgow Benefit Inventory (GBI) in patients undergoing transnasal endoscopic pituitary surgery for pituitary adenoma. METHODS: This was a retrospective cohort study in a UK tertiary referral centre. 145 patients who had undergone transnasal endoscopic pituitary surgery for pituitary adenoma over a 6-year period at one institution completed the GBI with at least 3 months' follow up. Patients with prior radiotherapy were excluded. The GBI is a patient-reported outcome measure that assesses post-intervention outcomes in three domains: 'general' functioning, 'social support' and 'physical' functioning. Pre- and post-operative visual loss scores were additionally assessed via a 1-5 Likert scale. GBI scores were assessed alongside these visual loss scores, clinical and surgical parameters and demographics. RESULTS: Mean age was 59.5 years (range 20-87 years) and mean follow up was 36 months. A total of 46 of 145 (31.7%) patients had secreting tumours. The most common primary symptom was visual loss. Mean total score for all patients was positive (+8.4); with 'general' domain score the most positive (+10.5). All patient groups had overall positive, 'general' and 'social support' domain scores. Patients with Cushing's disease reported significantly higher mean total scores (+29.6) than all other groups. Acromegaly (+7.9) and non-functioning adenoma (NFA) groups (+5.2) reported lower mean total scores. 'Physical' domain mean scores were negative for acromegaly and NFA groups. There was statistical significance between a pre- to post-operative improvement in visual score and mean total GBI score (p = 0.02) and mean 'general' domain GBI score (p = 0.02). CONCLUSIONS: These findings can aid preoperative counselling of patients undergoing this surgery. Those with NFA and no anticipated improvement to visual loss symptoms may be advised of possible worsened physical outcomes and of the option to delay the surgery until symptoms are present.

A systematic review of the feasibility and safety of day case nasal and/or palatopharyngeal surgery in patients with obstructive sleep apnoea.

INTRODUCTION: Recent guidelines suggest obstructive sleep apnoea (OSA) is not an absolute contraindication for same day discharge following surgery. The aim of this systematic review was to examine the feasibility and safety of day case nasal and/or palatopharyngeal surgery in patients with OSA. METHODS: We performed a systematic search of PubMed, EMBASE and the Cochrane library. Quality assessment of included studies was performed. The protocol of this systematic review was registered with PROSPERO (CRD42021273451). RESULTS: A total of 1836 patients from 10 observational studies were included. There were 268 (15.4%) nasal surgeries, 738 palatopharyngeal surgeries (42.4%) and 735 (42.2%) combined nasal and palatopharyngeal surgery. The majority of patients had moderate to severe OSA. A total of 860 patients (49.8%) were successfully discharged as day cases. There were no standard criteria for daycase surgery. Post-anaesthetic respiratory events were reported in 86/1750 (4.9%) patients. Oxygen desaturation was the most common respiratory event (83.7%, n = 72). There was no mortality reported. CONCLUSION: Current data suggests day surgery is feasible in carefully selected patients with OSA undergoing nasal and/or palatopharyngeal surgery. Further well-designed prospective studies with an emphasis on the systematic assessment of complications are required to establish safety and daycase criteria.

Pituitary apoplexy secondary to metastatic breast carcinoma into a gonadotroph cell adenoma of the pituitary.

A 65 year-old lady with metastatic breast cancer presented with pituitary apoplexy. Following surgery, histopathology confirmed metastatic breast carcinoma into a gonadotroph cell adenoma of the pituitary. Tumours that metastasise to a normal pituitary gland are unusual. More so, such neoplasm-to-neoplasm metastasis is extremely rare. This is, as far as we are aware, the first description of a metastasis into a gonadotroph cell pituitary adenoma presenting as apoplexy.

Pituitary apoplexy: how to define safe boundaries of conservative management? Early and long-term outcomes from a single UK tertiary neurosurgical unit.

OBJECTIVES: (1) Describe presentation, management and outcomes of a single-centre series of patients with pituitary apoplexy. (2) Compare early and long-term outcomes of conservative and surgical management. (3) Identify predictive factors for visual recovery. METHODS: Retrospective analysis of patients acutely managed by Sheffield's Neurosurgery over a 9-years period. Outcome comparison was made between 2 groups ('conservative' versus 'emergency') at early FU and 3 groups ('conservative' versus 'elective' versus 'emergency') at long-term FU. RESULTS: Data from 30 patients (M:F = 2.8:1; mean age: 54 years; median FU: 31.5 months) were collected. 86,7% patients presented with visual disturbances (70% acuity, 50% field, 50% diploplia). 10 (33%) patients underwent emergency surgery and further 8 underwent delayed elective surgery.At early FU, resolution rates of VA (33% versus 38%), VF (40% versus 50%) and CN deficits (71% versus 40%) were not significantly different between groups.At long-term FU, resolution of VA (80% versus 20% versus 75%) and CN deficits (67% versus 50% versus 80%) was not significantly different between groups. Most patients who underwent surgery presented with severe VA deficit (20% versus 40% versus 63%) but severity of initial deficit wasn't correlated with long-term resolution.VF recovery rates showed significant difference between groups (p = 0.027): 67% versus 0% versus 88%.Endocrine outcomes were generally poor, regardless of the management strategy.Regarding possible predictive factors, age and tumour size correlated with visual outcomes. Especially in patients treated conservatively in the acute phase, no cases of complete resolution of VA or VF deficit were recorded when tumour was higher than 35 mm. CONCLUSIONS: Good results are possible with conservative management in selected cases. Emergency surgery provides better visual outcomes. Decision-making process should be tailored to every single patient. We believe that a tumour vertical diameter >35 mm should tip the balance in favour of surgical management in presence of visual deficit.

Two unusual cases of lacrimal sac inflammatory polyps with allergic mucin sine fungi.

This case report deals with two patients with lacrimal sac swellings. Case 1 presented with bilateral sac swelling and Case 2 with a unilateral presentation. Dacrocystorhinostomy (DCR) followed by biopsies of both sacs in Case 1 revealed inflammatory polyps of the sac mucosa, identical in appearance to typical nasal allergic inflammatory polyps. The biopsies were accompanied by typical allergic mucin, featuring tiered mucin layers between which were numerous eosinophils, accompanied by Charcot-Leyden crystals. The histology of the dacryocystectomy specimen for Case 2 showed identical histopathological changes with the additional feature of prominent numbers of Immunoglobulin G (IgG)4-positive plasma cells in the stroma of the lacrimal sac inflammatory polyps. These features extend the sites affected by allergic inflammatory polyps and allergic mucin and possible pathogenesis is discussed.

Pituitary tumour apoplexy within prolactinomas in children: a more aggressive condition?

OBJECTIVES: To evaluate clinical presentations, diagnosis and management of paediatric patients presenting with pituitary apoplexy. METHODS: A retrospective case series describing a cohort of paediatric patients presenting with this condition from 2010-2016 to a tertiary referral children's hospital in the United Kingdom. RESULTS: Pituitary apoplexy is a rare condition that seems to have a higher relative incidence in children than adults. Our series suggests that pituitary apoplexy in paediatric patients with adenomas appears more common than previously described. All our patients required surgery, either as an acute or delayed procedure, for visual compromise. Two patients had commenced growth hormone (GH) for GH deficiency two weeks prior to the onset of pituitary apoplexy. CONCLUSIONS: With only a limited number of published case reports surrounding this topic our case series contributes to help further understand and manage this condition.

Immunoglobulin G4-related disease of the paranasal sinuses.

Immunoglobulin G4-related disease (IgG4-RD) is becoming increasingly documented. It was first described in relation to autoimmune pancreatitis. Features of the disease include tissue infiltration by IgG4 plasma cells with associated fibrosis and the growth of pseudotumours. A 71-year-old woman presented with increasing right cheek swelling and mild proptosis. Ten years earlier, she had a similar presentation and was diagnosed with an inflammatory pseudotumour. Examination revealed a lesion in the right nasal cavity. CT and MRI confirmed a mass within the right maxillary antrum extending into the nasal cavity. Endoscopic biopsies showed florid plasma cell infiltrate with marked increase in IgG+ plasma cells. Immunostaining expressed IgG4 (70%). She was started on a course of prednisolone and her symptoms resolved. IgG4-RD is becoming an emerging disease entity. Its involvement in the paranasal sinuses can mimic nasal tumours. Major surgical resection should be avoided as patients can often be treated medically.

Radiological features for the approach in trans-sphenoidal pituitary surgery.

INTRODUCTION: In order to perform trans-sphenoidal endoscopic pituitary surgery safely and efficiently it is important to identify anatomical and pituitary disease features on the pre-operative CT and MRI scans; thereby minimising the risk to surrounding structures and optimising outcomes. We aim to create a checklist to streamline pre-operative planning. METHODS: We retrospectively reviewed pre-operative CT and MRI scans of 100 adults undergoing trans-sphenoidal endoscopic pituitary surgery. RESULTS: Radiological findings and their incidence included deviated nasal septum (62%), concha bullosa (32%), bony dehiscence of the carotid arteries (18%), sphenoid septation overlying the internal carotid artery (24% at the sella) and low lying CSF (32%). The mean distance of the sphenoid ostium to the skull base was 10 mm (range 2.7-17.6 mm). We also describe the 'teddy bear' sign which when present on an axial CT indicates the carotid arteries will be identifiable intra-operatively. CONCLUSIONS: There are significant variations in the anatomical and pituitary disease features between patients. We describe a number of features on pre-operative scans and have devised a checklist including a new 'teddy bear' sign to aid the surgeon in the anatomical assessment of patients undergoing trans-sphenoidal pituitary surgery.

The Pathophysiology of Early Hypotension Following Epinephrine-containing Local Anesthetic Infiltration of the Nasal Mucosa in Patients Undergoing Endoscopic Transsphenoidal Hypophysectomy: A Prospective, Observational Study.

In patients undergoing endoscopic transsphenoidal hypophysectomy, the nasal mucosa is often infiltrated with local anesthetic solutions that contain epinephrine to aid hemostasis. This may, however, result in hemodynamic changes, especially hypotension. We characterized the cardiovascular changes using a LiDCOrapid monitor in 13 patients after the infiltration of 4% articaine containing 1:200,000 epinephrine. Nine (69%) had a >20% decrease in mean arterial pressure at a median time of 116 seconds after the infiltration of articaine with epinephrine. Analysis of the cardiac output data revealed that this was caused by a sustained reduction in systemic vascular resistance. The arterial blood pressure normalized over a period of 60 to 90 seconds secondary to increases in stroke volume and heart rate producing an elevation in cardiac output. Transient hypotension following the infiltration of epinephrine-containing local anesthetics may be caused by epinephrine stimulation of ß2-adrenoceptors producing vasodilation.

Endoscopic removal of a dermoid cyst via scalp incision.

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2-year-old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar.

Comparison of endoscopic and microscopic trans-sphenoidal pituitary surgery: early results in a single centre.

INTRODUCTION: Pituitary surgery has seen a recent shift from a microscopic to an endoscopic trans-sphenoidal approach. We present our early experience with endoscopic surgery and compare the outcome with our recent microscopic experience. METHODS: From January 2008 until present time, 80 consecutive patients underwent trans-sphenoidal pituitary surgery in our institution. Until September 2009, all patients had a microscopic trans-septal approach. After this time, the patients underwent endoscopic trans-sphenoidal surgery. All patients underwent pre- and post-operative MRI and full endocrinological evaluation. Data was collected prospectively including tumour volume, endocrine function, visual function, length of stay and complications. RESULTS: There were 40 patients in each group. In the microscopic group, there were 26 non-functioning tumours and 14 functioning tumours. In the endoscopic group, there were 24 non-functioning and 16 functioning tumours. There were significantly better results in terms of tumour resection (p = 0.002) and remission (p = 0.018) in the endoscopic group. In this group there was also a lower incidence of CSF leaks and a shorter length of stay for secreting tumours (p = 0.005). 1 patient in the endoscopic group died at day 43 post-operatively, having initially presented in a poor clinical state with pituitary apoplexy. CONCLUSION: Microscopic trans-sphenoidal surgery remains the benchmark for future surgical techniques. Our early results suggest that endoscopic trans-sphenoidal surgery provides favourable results in both tumour resection and control of secreting tumours in comparison with microscopic surgery. Further longer-term evaluation is required to ensure the outcome of endoscopic surgery.

Endoscopic endonasal resection of the odontoid peg for paediatric basilar invagination.

Osteogenesis imperfecta (OI) is a genetic disorder whose primary manifestations are fractures, bone deformity and bone pain. Brainstem compression due to basilar invagination is a rare and potentially life-threatening complication of OI. Children with this condition often require significant medical input and multiple admissions to hospital. Traditionally, anterior decompression is carried out through an open trans-oral route. We describe an endoscopic endonasal approach for resection of the peg in a child with OI and basilar invagination. We believe this approach provides an excellent alternative with minimal morbidity and decreased length of stay especially in the paediatric population.

Radiofrequency coblation for the resection of head and neck malignancies.

OBJECTIVE: To review the safety and efficacy of the use of radiofrequency coblation for endoscopic resection of upper aerodigestive tract malignancies and to compare length of procedures using coblation with CO(2) laser surgery. STUDY DESIGN AND SETTING: A retrospective case-note review of 40 adult patients with endoscopically treated mucosal squamous cell carcinoma of the head and neck, 20 having undergone resection using radiofrequency coblation and being case-matched to 20 treated with CO(2) laser. RESULTS: Coblation proved to be an effective method for resection of selected head and neck malignancies. It allows for much faster resection times than the CO(2) laser (P = 0.017) especially in the oropharynx (P = 0.007), but the large probes currently available can cause problems in assessment of adequate resection margins. CONCLUSIONS: Although current probe design limits the potential for resection of some tumors, radiofrequency coblation appears to be an attractive evolving technique for the endoscopic resection of selected upper aerodigestive tract malignancies.

Carcinoma arising in a pharyngeal pouch previously treated by endoscopic stapling.

OBJECTIVES: A case is described in which squamous cell carcinoma was found during surgery for a recurrent pharyngeal pouch previously treated by endoscopic stapling. A search of the English language literature suggests this is the first reported case of a carcinoma developing in a pharyngeal pouch previously treated by endoscopic stapling. STUDY DESIGN: Case report and literature review. MATERIALS AND METHODS: The records of a patient who presented with a recurrent pharyngeal pouch after a previous endoscopic stapling procedure were reviewed. The presentation, imaging, and histopathologic findings are presented and the implications of these discussed. RESULTS: Imaging confirmed a recurrent pharyngeal diverticulum. An endoscopic assessment revealed the presence of tumor in the recurrent pouch that histopathologic evaluation confirmed to be squamous cell carcinoma. The patient underwent an external excision of this diverticulum followed by a course of external beam radiotherapy. CONCLUSIONS: This is the first reported case of a carcinoma developing in a recurrent pharyngeal diverticulum previously treated by endoscopic stapling and brings to light a rare risk of endoscopic stapling procedures for the treatment of pharyngeal diverticula.

Radiologic differentiation of intracranial epidermoids from arachnoid cysts.

OBJECTIVE: Intracranial epidermoids (cholesteatomas) mimic arachnoid cysts in their radiologic characteristics, especially in the cerebellopontine angle. It is essential to differentiate the two conditions because they warrant different therapeutic interventions. The objective of this study is to elucidate the different radiologic characteristics of the conditions. STUDY DESIGN AND SETTING: This was a retrospective study of 4 patients referred for a differential diagnosis and management of intracranial cystic lesions to the Departments of Neurotology/Neurosurgery and Neuroradiology in a tertiary referral university hospital. PATIENTS: Four patients of different age groups with cystic intracranial lesions, diagnosed epidermoid or arachnoid cysts, were chosen. A retrospective analysis of their case charts, radiologic and surgical interventions, and follow-up records was undertaken. METHODS: The imaging techniques used included computerized tomographic scans, magnetic resonance imaging (MRI) with T1, T2, proton-density, and gadolinium-enhanced T1 images. In addition, special MRI sequences were used that included fluid-attenuated inversion recovery and echo planar diffusion scanning. All the patients underwent an audiovestibular evaluation. RESULTS: Both lesions are characteristically well demarcated and have a homogeneous low density, similar to cerebrospinal fluid on computerized tomographic scan, showing no contrast enhancement. On MRI, epidermoids and arachnoid cysts usually appear hypointense on T1-weighted images and hyperintense on T2-weighted images. On fluid-attenuated inversion recovery, an arachnoid cyst tends to follow cerebrospinal fluid intensity, whereas an epidermoid becomes hyperintense. There are occasions when an epidermoid may appear as a low-intensity lesion on fluid-attenuated inversion recovery. This dilemma is resolved with the use of echo planar diffusion scanning, on which an epidermoid remains bright. CONCLUSION: The authors recommend the use of fluid-attenuated inversion recovery and diffusion sequence MRI when definitive radiologic diagnosis of cystic intracranial lesions becomes difficult with routine computerized tomographic scanning and MRI.