Clinical Photograph
An Elongated Pituitary Stalk Resembling the Lining of a Dermoid Cyst during Endoscopic Endonasal Approach
Otolaryngology– Head and Neck Surgery 2015, Vol. 153(1) 150–151 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815585509 http://otojournal.org
Devin Mistry, DO1,2, and Bryan Figueroa, MD3
No sponsorships or competing interests have been disclosed for this article.
Keywords skull base surgery, dermoid cyst, transsphenoidal pituitary approach, endoscopic endonasal approach Received February 1, 2015; revised April 10, 2015; accepted April 15, 2015.
A
38-year-old man presented to the ophthalmologist with a family history of glaucoma and was found to have a left temporal visual field deficit. He also complained of gynecomastia and had a mildly elevated prolactin level. Magnetic resonance imaging revealed a large mass expanding the sella, abutting the basilar artery, and extending into the prepontine cistern. The patient was taken to surgery for endoscopic endonasal resection of the mass. Upon entrance into the sella, keratinaceous, sebaceous material was encountered, and the mass was confirmed to be a dermoid cyst. The contents were easily evacuated, resulting in a large cavity. Gross total resection of the mass and its lining was achieved. During the dissection of the lining, the elongated pituitary stalk was encountered and nearly transected, as it resembled a fold in the lining of the cyst. This finding was unanticipated, as preoperative imaging did not suggest the stalk to be elongated or displaced.
Discussion The endoscopic endonasal approach (EEA) to skull base surgery has revolutionized the treatment of many skull base lesions. Dermoid cysts can be difficult to approach and may recur if gross total resection is not achieved.1 Outcomes have been greatly improved with the use of EEA.2 While EEA often affords a superior view of many of the skull base structures, one must recognize that structures may be distorted and perspective may be limited. As it was in this case, the pituitary stalk may be elongated or convoluted by a sellar or suprasellar mass. Resembling a fold as the lining was dissected, the pituitary stalk was initially difficult to recognize, putting it at risk for injury or transection. This photograph (Figure 1) demonstrates the excellent view of skull base structures that were traditionally difficult to approach; however, it also demonstrates the deceptive
Figure 1. Cavity following dermoid cyst resection. The elongated pituitary stalk can be visualized on the left. BA, basilar artery; CA, carotid artery; CN3, oculomotor nerve; MB, mammillary bodies; PCA, posterior cerebral artery; PPC, prepontine cistern; PS, pituitary stalk; SCA, superior cerebellar artery.
positions in which they may lie. One must remain cognizant of the fact that the 2-dimensional view afforded by the endoscope may make it difficult to recognize distorted anatomy, risking vascular or neural injury. This case was reviewed by the Metro Health Institutional Review Board and exempted from approval, as it did not meet the Department of Health and Human Services standards for research. Author Contributions Devin Mistry, primary author, intellectual contributor, final approval; Bryan Figueroa, surgeon, intellectual contributor, reviewer and reviser of manuscript, final approval
1
Metro Health Hospital, Wyoming, Michigan, USA Michigan State University College of Osteopathic Medicine, Grand Rapids, Michigan, USA 3 Great Lakes Neurosurgical Associates, Grand Rapids, Michigan, USA 2
Corresponding Author: Devin Mistry, DO, Otolaryngology/Head and Neck Surgery Resident, Michigan State University College of Osteopathic Medicine, 926 Fairwood Ct, Jenison, MI 49428, USA. Email: [email protected]
Downloaded from oto.sagepub.com at Monash University on November 17, 2015
Mistry and Figueroa
151
Disclosures
epidermoid tumors: an experience with 33 patients. Surg Neurol Int. 2014;5:163. 2. McCoul ED, Chow S, Lee DL, Anand VK, Schwartz TH. Endoscopic endonasal approach for resection of ventral skull base keratinaceous cysts. Int Forum Allergy Rhinol. 2012;2: 258-263.
Competing interests: None. Sponsorships: None. Funding source: None.
References 1. Lynch JC, Aversa A, Pereira C, Nogueira J, Goncxalves M, Lopes H. Surgical strategy for intracranial dermoid and
Downloaded from oto.sagepub.com at Monash University on November 17, 2015
An Elongated Pituitary Stalk Resembling the Lining of a Dermoid Cyst during Endoscopic Endonasal Approach
Otolaryngology– Head and Neck Surgery 2015, Vol. 153(1) 150–151 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815585509 http://otojournal.org
Devin Mistry, DO1,2, and Bryan Figueroa, MD3
No sponsorships or competing interests have been disclosed for this article.
Keywords skull base surgery, dermoid cyst, transsphenoidal pituitary approach, endoscopic endonasal approach Received February 1, 2015; revised April 10, 2015; accepted April 15, 2015.
A
38-year-old man presented to the ophthalmologist with a family history of glaucoma and was found to have a left temporal visual field deficit. He also complained of gynecomastia and had a mildly elevated prolactin level. Magnetic resonance imaging revealed a large mass expanding the sella, abutting the basilar artery, and extending into the prepontine cistern. The patient was taken to surgery for endoscopic endonasal resection of the mass. Upon entrance into the sella, keratinaceous, sebaceous material was encountered, and the mass was confirmed to be a dermoid cyst. The contents were easily evacuated, resulting in a large cavity. Gross total resection of the mass and its lining was achieved. During the dissection of the lining, the elongated pituitary stalk was encountered and nearly transected, as it resembled a fold in the lining of the cyst. This finding was unanticipated, as preoperative imaging did not suggest the stalk to be elongated or displaced.
Discussion The endoscopic endonasal approach (EEA) to skull base surgery has revolutionized the treatment of many skull base lesions. Dermoid cysts can be difficult to approach and may recur if gross total resection is not achieved.1 Outcomes have been greatly improved with the use of EEA.2 While EEA often affords a superior view of many of the skull base structures, one must recognize that structures may be distorted and perspective may be limited. As it was in this case, the pituitary stalk may be elongated or convoluted by a sellar or suprasellar mass. Resembling a fold as the lining was dissected, the pituitary stalk was initially difficult to recognize, putting it at risk for injury or transection. This photograph (Figure 1) demonstrates the excellent view of skull base structures that were traditionally difficult to approach; however, it also demonstrates the deceptive
Figure 1. Cavity following dermoid cyst resection. The elongated pituitary stalk can be visualized on the left. BA, basilar artery; CA, carotid artery; CN3, oculomotor nerve; MB, mammillary bodies; PCA, posterior cerebral artery; PPC, prepontine cistern; PS, pituitary stalk; SCA, superior cerebellar artery.
positions in which they may lie. One must remain cognizant of the fact that the 2-dimensional view afforded by the endoscope may make it difficult to recognize distorted anatomy, risking vascular or neural injury. This case was reviewed by the Metro Health Institutional Review Board and exempted from approval, as it did not meet the Department of Health and Human Services standards for research. Author Contributions Devin Mistry, primary author, intellectual contributor, final approval; Bryan Figueroa, surgeon, intellectual contributor, reviewer and reviser of manuscript, final approval
1
Metro Health Hospital, Wyoming, Michigan, USA Michigan State University College of Osteopathic Medicine, Grand Rapids, Michigan, USA 3 Great Lakes Neurosurgical Associates, Grand Rapids, Michigan, USA 2
Corresponding Author: Devin Mistry, DO, Otolaryngology/Head and Neck Surgery Resident, Michigan State University College of Osteopathic Medicine, 926 Fairwood Ct, Jenison, MI 49428, USA. Email: [email protected]
Downloaded from oto.sagepub.com at Monash University on November 17, 2015
Mistry and Figueroa
151
Disclosures
epidermoid tumors: an experience with 33 patients. Surg Neurol Int. 2014;5:163. 2. McCoul ED, Chow S, Lee DL, Anand VK, Schwartz TH. Endoscopic endonasal approach for resection of ventral skull base keratinaceous cysts. Int Forum Allergy Rhinol. 2012;2: 258-263.
Competing interests: None. Sponsorships: None. Funding source: None.
References 1. Lynch JC, Aversa A, Pereira C, Nogueira J, Goncxalves M, Lopes H. Surgical strategy for intracranial dermoid and
Downloaded from oto.sagepub.com at Monash University on November 17, 2015
