Pituitary macro adenoma-Trans-nasal trans-sphenoidal endoscopic excision
R. Shanthi
Nursing In charge, Kauvery Hospital Tirunelveli, India
Abstract
Pituitary macro adenoma presents with mass effects and potentially hormonal deficiency or hormonal excess. Pituitary apoplexy is a sudden hemorrhage into pituitary adenoma. It is very rare. First-line therapy for pituitary adenomas is usually Trans sphenoidal surgery.
Case presentation
A 44yrs old male was admitted on 17.01.24, known case of Type 2 Diabetic Mellitus. Since past 1year he had complaints of right hemianopia of sudden onset, not associated with headache, vomiting, and giddiness. In the month of November patient had visited a hospital due to persistence of symptoms, was advised to undergo MRI and to get a neurologist consult.
Patient was diagnosed as a case of Pituitary Macro adenoma raising from Sella and suprasellar area and was advised surgery. Patient was admitted in this hospital for surgical excision of the mass and hence this admission.
Past medical and medication History
- Not a known case of SHTN, epilepsy, thyroid.
- Type 2 Diabetic Mellitus under treatment (3 weeks)
- Has a history surgery which was done 7 years back for Lipoma (outside hospital)
On Examination
Patient was conscious and oriented.
HR: 78/mts, BP: 130/80mmHg, Temp: 98.6, RR :20, SpO2: 99%
CVC: S1, S2 present, RS: Bilateral air entry is present
P/A: Soft, CNS: NFND
Investigations
Hb: 13.8, PCV: 41.4, Platelet: 1.55L, Urea: 29, Creatinine: 0.8
RBS: 128
Blood Grouping: O+Ve
T3:2.86, T4: 1.17, TSH: 3.38
HIV: Negative, HbsAg: Negative, HCV: Negative
CT scan
Pituitary Macro adenoma
Course in the hospital
All routine and relevant investigation done.
Patient was diagnosed as Pituitary Macro adenoma. Anesthetic opinion taken. Patient was planned for surgery
Surgery Notes: 19.01.24
Patient underwent transnasal transphenoidal endoscopic excision on 19.01.24. Patient under ETGA, supine Position.
Using the Endoscope right Hadad flap raised, Sphenoid ostium reached, sphenoid opened, septum drilled floor of pituitary fossa drilled.
Dura opened in C Shaped manner; lesion was less suckable fibrous vascular Tumor.
Debulked Using Suction and curette. Near total excision done. After attaining complete hemostasis, pituitary floor was packed with surgical, fibrillary fat fascia lata , then with Hadad flap.
Both nostrils packed with meroceel.
Post procedure
Uneventful. Patient treated with Iv fluid, Iv antibiotics, H2 blockers, anti-inflammatory drugs and other supportive drugs. Patient condition improved.
Medications
- Inj. Ceftriaxone 1gm 1- 0 – 1
- Inj. Amikacin 500 mg 1 – 0 – 1
- Inj. Rantac 50 mg 1 – 0 – 1
- Inj. Ketanov 1 – 0 – 1
- Inj. Dexa 4 mg 1 – 1 – 1
- Inj. Pantocid 40 mg 1 – 0 – 0
Nursing management
- Vital signs are measured to monitor hemodynamic, cardiac stability
- Pain management given, patient was under close observation.
- Intake and output measured as a guide to fluid and electrolyte replacement.
- The nasal packing inserted during surgery was checked frequently for blood or CSF drainage. The major discomfort was then due to the nasal packing and then to mouth dryness and thirst from mouth breathing.
- Oral care was provided every 4 hours or more frequently when required.
Diet
The patient was advised to eat small, frequent meals, to include fruits and vegetables, fiber and bran in the diet and to avoid spicy or fried food.
Family was instructed that she may probably feel very fatigued for the first 2 weeks then will notice a gradual increase in energy thereafter.
Post-op Investigation
MRI – Impression
Post-operative hematoma in the Sella and supra Sella region. Post-operative defect seen in the Sella
Blood sugar
Fasting – 143 mg/dl
Post prandial – 113 mg/dl
Health education advised to follow at home
- To avoid leakage of cerebral spinal fluid
- Do not blow your nose or drink out of a straw for 4 weeks!
- Try to sneeze with your mouth open for 4 weeks to avoid generating high pressure in your head.
- Pain control: The most common type of pain experienced following this type of surgery is headache. Patient advised that he would be given a written prescription for pain medications upon discharge from the hospital.
- Advised to make certain that he would take his medications with food.
- Advised – Do not take ibuprofen or aspirin until 4 weeks after surgery. To sleep with head elevated on pillows which may help decrease headaches.
- Lifting: Try not to lift, push, or pull more than 10 pounds for 4 weeks after surgery.
- Activity: It is important to get out of bed and move as soon as possible after surgery to avoid developing problems such as blood clots or pneumonia.
- Walk with assistance if feeling unsteady. To get plenty of rest, avoid rigorous activity for 4 to 6 weeks after surgery.
- Exercise/Sports: No exercise for the first 2 weeks after surgery.
- Advised that, after 2 weeks, he may take short walks, gradually increasing the distance. At 4 weeks after surgery, he may begin to slowly return to his regular exercise routine.
- A headache is a sign that one may be doing too much too soon. Do not do anything with an increased risk of head trauma for 8 weeks after surgery (such as skiing, snowboarding, mountain biking, contact sports, etc.
- Work: Plan to be away from work for 4 weeks if he has a sedentary job and 6 weeks if you he has an active job
- Driving: May drive 1 week after surgery if no longer taking narcotic pain medications and not experiencing visual problems that affect your ability to drive.
Warning signs to report back to hospital;
- A temperature of 101 degrees or higher.
- Worsening headache not relieved by prescribed pain medications.
- Continuous faucet-like nasal drip or drainage of fluid down your throat.
- Continuous nosebleed.
- Significant changes in behaviour or ability to think.
- Persistent vomiting. Inability to keep down food or fluids.
- Inability to urinate or have a bowel movement. For symptoms that seem life-threatening.
Conclusion
Outcome of the patient was good, Vitals stable, hence discharged on 22.01.24 by the proper medical care.
R. Shanthi
Nursing In charge