An Unexpected Complication of Transsphenoidal Resection of Pituitary Adenoma

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Jérôme R. Lechien, MD, PhD, MS, Stelianos Kampouridis, MD, Serge D. Le Bon, MD, ...

First Published May 28, 2019 Other 

https://doi.org/10.1177/0145561319853522

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A 31-year-old migrant was referred to the Department of Otolaryngology–Head & Neck Surgery for a history of right hearing deafness. In 2003 and 2007, patient underwent 2 endonasal endoscopic surgical procedures for a pituitary prolactinoma in Africa. The patient came in Europe a few years after the second surgery time. Patient reported that the right deafness occurred immediately after the second surgery while the facial palsy developed a few weeks after the surgery; the etiology being never investigated over the past 11 years. According to the imaging report, the pituitary prolactinoma measured 2-cm diameter and was located in the sella turcica. The rest of the medical history included sleeve gastrectomy and obstructive apnea syndrome. At the examination, the patient had a right peripheral facial palsy. The tympanoscopy and the tympanometry were unremarkable. Audiometry reported a left hearing threshold of 20 dB; a right profound deafness. Computed tomography and magnetic resonance imaging showed a large surgical cavity in the temporal bone (petrous apex) with an opening of the lateral wall of the right sphenoidal sinus. The cavity was covered by an inflammatory mucosa, and there was a bone lysis of the wall of the cavity and the right wall of the clivus (Figure 1A-C). Magnetic resonance imaging (Fast Imaging Employing Steady-State Acquisition) showed a cochlea densification, which corresponds to a labyrinthitis ossificans (Figure 1D). Regarding the inflammatory reaction and the bone modifications related to the surgery, there was a compression of the first portion of the facial nerve at the internal auditory canal (Figure 1D). The diagnostic of a false surgical way was retained according to the history of the symptoms; the imaging findings and the lack of initial lesion in the petrous apex.

Figure 1. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the surgical cavity. Axial CT (A), axial T1 (C), and coronal T2 MRI (B) showed a large surgical cavity in the temporal bone with an opening of the lateral wall of the right sphenoidal sinus (long arrow). The cavity was covered by an inflammatory mucosa (A, C; small arrow), and there was a bone lysis of the wall of the cavity and the right wall of the clivus (A; dotted arrow). Axial MRI (Fast Imaging Employing Steady-State Acquisition [FIESTA]) showed a cochlea densification, which corresponds to a labyrinthitis ossificans (D; dotted arrow).

Pituitary adenoma is a common tumor with an incidence rate from 0.22 to 1.22 per 100 000 population in United States.¹ Regarding the development of endoscopic sinus surgery approaches over the last decades, the transsphenoidal resection of pituitary tumor has become a reference surgical procedure for the treatment of these tumors. The most reported postoperative complications of transsphenoidal surgery are postoperative cerebrospinal fluid leak, epistaxis, bleeding, visual deterioration, and meningitis.^2,3 In this article, we reported an unexpected complication of transsphenoidal surgery consisting of an aberrant surgical way through the posterolateral wall of the sphenoidal sinus in place of the posterosuperior wall. Thus, surgeon has removed the petrous apex parts, that is, cochlea, osseous, and membranous labyrinths leading to a right deafness and a facial palsy. To our knowledge, there is no similar complication described in the literature. This case highlights the importance of knowing the anatomy of the skull basis and the paranasal cavities, which remains the basis of the surgery.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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