Transsphenoidal approach

As an alternative to the transcranial route the transsphenoidal approach was developed simultaneously in the first decade of the 20th century in the United States and in Europe, in particular in the Austrian monarchy. One reason that Vienna became the cradle for the minimally invasive approach to pituitary tumors using an endonasal transsphenoidal approach was among others due to the basic and detailed anatomical studies of the paranasal sinuses performed in Vienna by the Austrian anatomist and Violin virtuoso Emil Zuckerkandl (1849–1910). His main work “On normal and pathological anatomy of the paranasal sinus and its pneumatic adnexes” in 1882 was the anatomical presupposition for the Viennese ENT surgeons to successfully develop minimally invasive endonasal approaches to pituitary tumors 1).

Initially described by Hans Schloffer 2) and Cushing 3) and subsequently popularized by Guiot 4) and Hardy and Wigser 5), the transsphenoidal approach to the sella now represents the preferred approach for removing pituitary adenomas. Traditionally performed with a microscope and a sublabial incision, the implementation of the endoscope and endonasal access has rendered the transsphenoidal approach less invasive and provided improved visualization into and around the sella.

Endoscopic transsphenoidal approach.

see Transsphenoidal approach guidelines.

see Transsphenoidal approach for pituitary tumor.

Transsphenoidal surgery can safely be performed in the setting of chronic rhinosinusitis (CRS) without increased risk of intracranial complications 6).

1. for transsphenoidal approach: Polysporin® ointment (PSO) applied in both nostrils the night before surgery

2. antibiotics: e.g. Unasyn® 1.5 gm (1 gm ampicillin + 0.5 gm sulbactam) IVPB at MN & 6 AM

3. steroids, either:

a) hydrocortisone sodium succinate(Solu-Cortef®)50mg IM at 11 PM & 6 AM.On call to OR: hang 1 L D5LR + 20 mEq KCl/l + 50 mg Solu-Cortef at 75 ml/hr


b) hydrocortisone 100mg PO at MN&IV at 6AM

4. intra-op: continue 100 mg hydrocortisone IV q 8 hrs

see Transsphenoidal approach complications.

Difficulties achieving radical resection with this method are encountered in patients with pituitary adenomas (PA) invading the cavernous sinus (CS), due to the inability of the standard transsphenoidal approach to expose all tumors adequately.

Transsphenoidal approach case series.

Zuckerkandl E. Normale und pathologische Anatomie der Nasenhöhlen und ihrer pneumatisierten Anhänge. Vienna, Austria: Braumüller; 1882.
Schloffer H: Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege [Successful operation of a hypophyseal tumor through the nasal pas- sage]. Wien Klin Wochnschr 20:621–624, 1907.
Cushing H: III. Partial hypophysectomy for acromegaly: With remarks on the function of the hypophysis. Ann Surg 50:1002–1017, 1909.
Guiot G: Transsphenoidal approach in the surgical treatment of pituitary adenomas: General principles and indications in non-functioning adenomas, in Kohler PO, Ross GT (eds): Diagnosis and Treatment of Pituitary Tumors. New York, American Elsevier, 1973, pp 159–178.
Hardy J, Wigser SM: Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 23:612–619, 1965.
Schaberg MR, Shah GB, Evans JJ, Rosen MR. Concomitant transsphenoidal approach to the anterior skull base and endoscopic sinus surgery in patients with chronic rhinosinusitis. J Neurol Surg B Skull Base. 2013 Aug;74(4):241-6. doi: 10.1055/s-0033-1342916. Epub 2013 Apr 3. PubMed PMID: 24436919.
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