This surgery uses special cameras and instruments to operate through the nasal space on tumours in the pituitary gland and the skull base in front of and behind the pituitary gland. This surgery requires subspeciality training and again involves the collaboration of expert teams of ENT and neurosurgeons working together. These techniques have expanded the types of tumours that may be removed through this route and allow better visualisation and so more complete removal of tumours that have traditionally been more difficult to remove via this route.
Indications for surgery: Hormone secreting pituitary tumours (except prolactinomas) or pituitary tumours compressing surrounding structures. Tumours of the clivus or anterior cranial fossa.Other tumours arising from or within the sellaturcica.Odontoid brainstem compression (cranial settling).
Evidence for surgery: Surgical removal of hormone producing pituitary tumours or compressive tumours is the most effective treatment with the best chance or hormonal control and relief of pressure effects on surrounding structures.
Benefits of surgery: Hormone control to give the best chance of cure from these tumours. Return of function from compressed structures such as return of vision following compression of the eye nerves. Removal of tumours not previously suitable for surgical treatment.
Risks of surgery: Like all complex major brain surgery this carries a small risk of death, stroke and major disability. Risks also include arterial injury, blindness, infection / meningitis, loss of smell, CSF leakage, incomplete tumour removal, further tumour surgery and bleeding and crusting in the nose. As with all surgery there are risks relating to anaesthesia and post-operative medical risks such as blood clots and infections. Hormone replacement (tablets / sprays) may be needed to supplement the function of the pituitary gland after the surgery. The specific risks of your surgery will depend on the nature of your tumour and will be detailed before you make the decision to embark on surgery.
Post operatively care is in the neurosurgical high dependency unit with close monitoring of neurological function. You may wake up with packing or a surgical balloon in the nose. The operation is not usually painful but the nose may feel blocked and the face may feel ‘puffy’ after the surgery. Particular care is taken to ensure all of the normal pituitary hormones and the bodys salt balance are monitored after surgery. This will continue for several weeks and is performed together with the endocrinology (hormone) team. Particular care is also taken to ensure there is no leakage of brain and spine fluid (CSF) after the surgery from the nose. CSF leakage is manifested as a steady dripping of clear, salty tasting fluid either from the nose if leaning forward, or in the back of the throat when leaning back. The taste of the fluid is unpleasant. It is normal to have some blood and weeping from the nose surgery itself but if the fluid drip is steady and associated with headache you should return to the hospital. If we are unclear as to the nature of the fluid we can give you a specimen pot to obtain a sample and test the sample to prove it is CSF.
Post-operative stay is typically a few days following the surgery with an early outpatient appointment for a check of the nose with the ENT surgeons. You should wash out the nose several times a day with a special FESS spray as directed by the ENT surgeons.
If you are on hormone replacement tablets it is critical you take the tablets as directed by the endocrinologists. If you run out you need to obtain more tablets as they are very important. If you feel unwell you need to have urgent blood tests to make sure your salt levels are normal. This can be performed at your local emergency department. If you have fluid leakage from the nose you should present to your or the Royal Melbourne hospital emergency department.
You should not plan to return to work for 6 weeks after the surgery. During this time you will be tired and sleep more than usual. You should however be easily rousable. You should walk and perform light exercise but nothing strenuous. You should avoid blowing your nose. If your vision is normal and you are in full control of the car even in an emergency situation you may drive your car as long as the operation only involved the pituitary gland and not the brain itself. In that case you cannot drive until instructed to do so my myself or a neurologist.
After six weeks most likely you will be suitable to return to work in a graduated manner building up your hours and activities slowly over 3 months.