A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

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  • 1 Departments of Otolaryngology and
  • 2 Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri;
  • 3 Division of Pediatric Otololaryngology, Children's Hospital of Philadelphia; and
  • 4 Department of Otorhinolaryngology/Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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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.

In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized.

This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.

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Contributor Notes

Address correspondence to: Richard A. Chole, M.D., Ph.D., Department of Otolaryngology—Head and Neck Surgery, Campus Box 8115, 660 South Euclid Avenue, St. Louis, Missouri 63110. email: rchole@wustl.edu.

Please include this information when citing this paper: published online January 7, 2011; DOI: 10.3171/2010.11.JNS101167.

  • 1

    Alfieri A: Endoscopic endonasal transsphenoidal approach to the sellar region: technical evolution of the methodology and refinement of a dedicated instrumentation. J Neurosurg Sci 43:8592, 1999

    • Search Google Scholar
    • Export Citation
  • 2

    Alfieri A, & Jho HD: Endoscopic endonasal approaches to the cavernous sinus: surgical approaches. Neurosurgery 49:354362, 2001

  • 3

    Alfieri A, & Jho HD: Endoscopic endonasal cavernous sinus surgery: an anatomic study. Neurosurgery 48:827837, 2001

  • 4

    Alfieri A, , Jho HD, , Schettino R, & Tschabitscher M: Endoscopic endonasal approach to the pterygopalatine fossa: anatomic study. Neurosurgery 52:374380, 2003

    • Search Google Scholar
    • Export Citation
  • 5

    Alfieri A, , Jho HD, & Tschabitscher M: Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study. Acta Neurochir (Wien) 144:219225, 2002

    • Search Google Scholar
    • Export Citation
  • 6

    Arita K, , Kurisu K, , Tominaga A, , Ohba S, , Ikawa F, & Iida K, : Transsphenoidal “cross court” approach using a slightly modified speculum to reach pituitary adenomas with lateral growth. Acta Neurochir (Wien) 142:10551058, 2000

    • Search Google Scholar
    • Export Citation
  • 7

    Aust MR, , McCaffrey TV, & Atkinson J: Transnasal endoscopic approach to the sella turcica. Am J Rhinol 12:283287, 1998

  • 8

    Bohinski RJ, , Warnick RE, , Gaskill-Shipley MF, , Zuccarello M, , van Loveren HR, & Kormos DW, : Intraoperative magnetic resonance imaging to determine the extent of resection of pituitary macroadenomas during transsphenoidal microsurgery. Neurosurgery 49:11331144, 2001

    • Search Google Scholar
    • Export Citation
  • 9

    Cappabianca P, , Cavallo LM, , Colao A, , Del Basso De Caro M, , Esposito F, & Cirillo S, : Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg 45:193200, 2002

    • Search Google Scholar
    • Export Citation
  • 10

    Carrau RL, , Jho HD, & Ko Y: Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 106:914918, 1996

  • 11

    Charalampaki P, , Reisch R, , Ayad A, , Conrad J, , Welschehold S, & Perneczky A, : Endoscopic endonasal pituitary surgery: surgical and outcome analysis of 50 cases. J Clin Neurosci 14:410415, 2007

    • Search Google Scholar
    • Export Citation
  • 12

    Cooke RS, & Jones RA: Experience with the direct transnasal transsphenoidal approach to the pituitary fossa. Br J Neurosurg 8:193196, 1994

    • Search Google Scholar
    • Export Citation
  • 13

    Cushing H: The Weir Mitchell Lecture: Surgical experiences with pituitary disorders. J Am Med Assoc 63:15151525, 1914

  • 14

    Dabb RW, & Aker JS: The external rhinoplasty approach for the treatment of acromegaly. Ann Plast Surg 32:630637, 1994

  • 15

    de Divitiis E, , Cappabianca P, & Cavallo LM: Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 51:699707, 2002

    • Search Google Scholar
    • Export Citation
  • 16

    Faria MA Jr, & Tindall GT: Transsphenoidal microsurgery for prolactin-secreting pituitary adenomas. J Neurosurg 56:3343, 1982

  • 17

    Gamea A, , Fathi M, & el-Guindy A: The use of the rigid endoscope in trans-sphenoidal pituitary surgery. J Laryngol Otol 108:1922, 1994

  • 18

    Garcia AS, & Rhoton AL Jr: Speculum opening in transsphenoidal surgery. Neurosurgery 59:1 Suppl 1 ONS35ONS40, 2006

  • 19

    Griffith HB, & Veerapen R: A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurg 66:140142, 1987

  • 20

    Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:582594, 1971

  • 21

    Hardy J, & Wigser SM: Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 23:612619, 1965

    • Search Google Scholar
    • Export Citation
  • 22

    Heilman CB, , Shucart WA, & Rebeiz EE: Endoscopic sphenoidotomy approach to the sella. Neurosurgery 41:602607, 1997

  • 23

    Helal MZ: Combined micro-endoscopic trans-sphenoid excisions of pituitary macroadenomas. Eur Arch Otorhinolaryngol 252:186189, 1995

  • 24

    Jane JA Jr, , Han J, , Prevedello DM, , Jagannathan J, , Dumont AS, & Laws ER Jr: Perspectives on endoscopic transsphenoidal surgery. Neurosurg Focus 19:6 E2, 2005

    • Search Google Scholar
    • Export Citation
  • 25

    Jankowski R, , Auque J, , Simon C, , Marchal JC, , Hepner H, & Wayoff M: Endoscopic pituitary tumor surgery. Laryngoscope 102:198202, 1992

  • 26

    Jarrahy R, , Berci G, & Shahinian HK: Assessment of the efficacy of endoscopy in pituitary adenoma resection. Arch Otolaryngol Head Neck Surg 126:14871490, 2000

    • Search Google Scholar
    • Export Citation
  • 27

    Jho HD: Endoscopic pituitary surgery. Pituitary 2:139154, 1999

  • 28

    Jho HD, & Alfieri A: Endoscopic removal of third ventricular tumors: a technical note. Minim Invasive Neurosurg 45:114119, 2002

  • 29

    Jho HD, & Carrau RL: Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 87:4451, 1997

  • 30

    Jho HD, & Carrau RL: Endoscopy assisted transsphenoidal surgery for pituitary adenoma. Technical note. Acta Neurochir (Wien) 138:14161425, 1996

    • Search Google Scholar
    • Export Citation
  • 31

    Jho HD, , Carrau RL, , Ko Y, & Daly MA: Endoscopic pituitary surgery: an early experience. Surg Neurol 47:213223, 1997

  • 32

    Jho HD, , Carrau RL, , McLaughlin MR, & Somaza SC: Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa. Acta Neurochir (Wien) 139:343348, 1997

    • Search Google Scholar
    • Export Citation
  • 33

    Jho HD, , Carrau RL, , McLaughlin ML, & Somaza SC: Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa. Case report. Neurosurg Focus 1:1 e3, 1996

    • Search Google Scholar
    • Export Citation
  • 34

    Jho HD, & Ha HG: Endoscopic endonasal skull base surgery: Part 1—The midline anterior fossa skull base. Minim Invasive Neurosurg 47:18, 2004

    • Search Google Scholar
    • Export Citation
  • 35

    Jho HD, & Ha HG: Endoscopic endonasal skull base surgery: Part 2—The cavernous sinus. Minim Invasive Neurosurg 47:915, 2004

  • 36

    Jho HD, & Ha HG: Endoscopic endonasal skull base surgery: Part 3—The clivus and posterior fossa. Minim Invasive Neurosurg 47:1623, 2004

    • Search Google Scholar
    • Export Citation
  • 37

    Kanaan IN: Minimally invasive approach to management of pituitary adenomas. Minim Invasive Neurosurg 48:169174, 2005

  • 38

    Kennedy DW: Functional endoscopic sinus surgery. Technique. Arch Otolaryngol 111:643649, 1985

  • 39

    Killian G: Die sumucose Fensterresektion der Nasenscheiwand. Arch Laryngologie Rhinologie 16:362394, 1904

  • 40

    Kim EY, , Park HS, , Kim JJ, , Han HS, , Nam MS, & Kim YS, : Endoscopic transsphenoidal approach through a widened nasal cavity for pituitary lesions. J Clin Neurosci 8:437441, 2001

    • Search Google Scholar
    • Export Citation
  • 41

    Koren I, , Hadar T, , Rappaport ZH, & Yaniv E: Endoscopic transnasal transsphenoidal microsurgery versus the sublabial approach for the treatment of pituitary tumors: endonasal complications. Laryngoscope 109:18381840, 1999

    • Search Google Scholar
    • Export Citation
  • 42

    Kuroki A, & Kayama T: Endoscopic approach to the pituitary lesions: contemporary method and review of the literature. Biomed Pharmacother 56:Suppl 1 158s164s, 2002

    • Search Google Scholar
    • Export Citation
  • 43

    Landolt AM, & Novoselac M: Modification of the Cushing speculum used for transsphenoidal pituitary surgery. Technical note. J Neurosurg 42:108110, 1975

    • Search Google Scholar
    • Export Citation
  • 44

    Miyake H, & Ohta T: Modification of a nasal speculum for transsphenoidal surgery. Technical note. J Neurosurg 92:359360, 2000

  • 45

    Moreland DB, , Diaz-Ordaz E, & Czajka GA: Endoscopic endonasal hemisphenoidotomy for resection of pituitary lesions confined to the sella: report of 3 cases and technical note. Minim Invasive Neurosurg 43:5761, 2000

    • Search Google Scholar
    • Export Citation
  • 46

    Nakagawa T, , Takashima T, , Tomiyama K, & Asada M: [Approaches to sella turcica in endoscopic pituitary surgery.]. Nippon Jibiinkoka Gakkai Kaiho 104:18, 2001. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 47

    Nakao N, , Nakai K, & Itakura T: A minimally invasive endoscopic transsphenoidal approach with an endonasal septal pushover technique by using a modified nasal speculum. Minim Invasive Neurosurg 49:2024, 2006

    • Search Google Scholar
    • Export Citation
  • 48

    Papay FA, , Stein JM, , Rhoten RL, , Luciano M, , Zins J, & Hahn J: Transnasal transseptal endoscopic approach to the sphenoid sinus. J Craniofac Surg 8:159163, 1997

    • Search Google Scholar
    • Export Citation
  • 49

    Parnes SM, & Koltai PJ: External rhinoplasty approach to transsphenoidal hypophysectomy. Ear Nose Throat J 70:438440, 1991

  • 50

    Rodziewicz GS, , Kelley RT, , Kellman RM, & Smith MV: Transnasal endoscopic surgery of the pituitary gland: technical note. Neurosurgery 39:189193, 1996

    • Search Google Scholar
    • Export Citation
  • 51

    Rosen MR, , Saigal K, , Evans J, & Keane WM: A review of the endoscopic approach to the pituitary through the sphenoid sinus. Curr Opin Otolaryngol Head Neck Surg 14:613, 2006

    • Search Google Scholar
    • Export Citation
  • 52

    Sethi DS, & Pillay PK: Endoscopic management of lesions of the sella turcica. J Laryngol Otol 109:956962, 1995

  • 53

    Shikani AH, & Kelly JH: Endoscopic debulking of a pituitary tumor. Am J Otolaryngol 14:254256, 1993

  • 54

    Stranjalis G, , Stavrinou LC, , Kouyialis AT, & Sakas DE: A modified speculum for transsphenoidal surgery: technical note. Neurosurg Rev 32:491494, 2009

    • Search Google Scholar
    • Export Citation
  • 55

    Styne DM, , Grumbach MM, , Kaplan SL, , Wilson CB, & Conte FA: Treatment of Cushing's disease in childhood and adolescence by transsphenoidal microadenomectomy. N Engl J Med 310:889893, 1984

    • Search Google Scholar
    • Export Citation
  • 56

    Thomas RF, , Monacci WT, & Mair EA: Endoscopic image-guided transethmoid pituitary surgery. Otolaryngol Head Neck Surg 127:409416, 2002

  • 57

    Tucker HM, & Hahn JF: Transnasal, transeptal sphenoidal approach to hypophysectomy. Laryngoscope 92:5557, 1982

  • 58

    Wilson WR, & Laws ER Jr: Transnasal septal displacement approach for secondary transsphenoidal pituitary surgery. Laryngoscope 102:951953, 1992

    • Search Google Scholar
    • Export Citation
  • 59

    Yamada S: Sublabial transsphenoidal pituitary surgery: a new modified technique for a less-invasive sublabial approach. Biomed Pharmacother 56:Suppl 1 165s170s, 2002

    • Search Google Scholar
    • Export Citation
  • 60

    Yaniv E, & Rappaport ZH: Endoscopic transseptal transsphenoidal surgery for pituitary tumors. Neurosurgery 40:944946, 1997

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