Former Golden Gloves middleweight Daniel Donovan knew he had a problem when he lost his peripheral vision. “I couldn’t see my wife when she was sitting right next to me in the car,” he said. He went to his ophthalmologist, who sent him to his internist. After a pituitary
Fortunately for Mr. Donovan and others with pituitary tumors, the pituitary gland is the new frontier in minimally invasive surgery. This pea-sized endocrine gland is located right in the middle of the head, nestling in the curve of the sella Tursica —“Turkish saddle”— the bony structure behind the sphenoid sinus. “Surgery to remove a pituitary tumor was once performed by entering the skull through the front of the head and then moving the brain aside to reveal the gland,” Dr. Shikowitz said. Today, however, otolaryngology and neurosurgery have partnered to blaze a new endoscopic trail to the pituitary.
Dr. Shikowitz began using the transnasal (entrance through a nostril) approach to skull-based surgery more than 20 years ago, wielding one of the first sets of endoscopic instruments ever manufactured.
Sinus and Neurosurgeons Partner
The new partnership of otolaryngology with neurosurgery to develop the endoscopic transnasal approach to pituitary tumors is what Dr. Shikowitz describes as a natural segue. Both he and another sinus surgeon with expertise in the endoscopic removal of pituitary tumors, B. Todd Schaeffer, MD, the associate chair of otolaryngology at North Shore University Hospital (NSUH), are doing this type of surgery in collaboration with neurosurgeons with the North Shore-LIJ Health System’s Harvey Cushing Institutes of Neuroscience.
Dr. Schaeffer teams with neurosurgeon Mark Eisenberg, MD, who performs an average of four skull base tumor removals every month at NSUH. “The goal of every skull base operation is to choose the path to the tumor that will disturb the brain least while allowing complete tumor removal,” Dr. Eisenberg explained. “Certain skull base tumors, particularly those located toward the front portion of the skull, are amenable to endoscopic techniques, using the normal nasal pathways as a minimally invasive route.”
The surgeons first provide access to the pituitary gland and the tumor by opening the back of the sphenoid sinus, using a thin endoscope. Then, the neurosurgeons remove the tumor while the otolaryngologists wield the endoscope to “light the stage,” providing a view of startling depth and clarity. The surgeon is aided by three-dimensional, intra-operative computed tomography (CT) scan/magnetic resonance imaging (MRI) guidance.
“There are 13 very sensitive structures located in the vicinity of the pituitary gland,” Dr. Shikowitz said, “including the carotid artery and the optic chiasma, where the optic nerves cross. [Mr. Donovan’s loss of peripheral vision was caused by pressure of the tumor on the optic nerves.] The otolaryngologist’s expertise in navigating that terrain is crucial.”
What made Mr. Donovan’s case particularly well suited for an otolaryngologist was that he had not only a pituitary tumor but a severely damaged septum — the strip of cartilage and thin bone between the nasal passages — the result of being hit in the nose too many times. (After retiring from the ring, Mr. Donovan trained professional fighters at clubs in Islip and Farmingdale, and partnered with the late middleweight champion Rocky Graziano to manage boxer Elliott Miller; he now works part-time for the Town of Oyster Bay.) Giving him that 1-2 punch, Dr. Shikowitz performed extensive repairs to Mr. Donovan’s septum as he cleared the path for Dr. Mechanic to remove the tumor.
Before he was admitted to North Shore-LIJ for the procedure, Mr. Donovan minimized its seriousness to his family, friends and co-workers, but he was understandably apprehensive about having “almost” brain surgery, minimally invasive or not. He was surprised and delighted to experience very little post-operative discomfort and to be back at work in two days. With this type of endoscopic surgery, there is less pain, scarring and lip numbness. Mr. Donovan’s tumor was benign, as pituitary tumors usually are. Full vision was restored, and thanks to the septum repair, “I’m breathing better than I have in years.” (Mrs. Donovan regretfully reported that the repair did not cure her husband’s snoring.)
While Mr. Donovan is happy to have his health crisis behind him, Dr. Shikowitz looks forward with excitement to further advances. “As scopes and guidance systems evolve,” he said, “we’ll be pushing the envelope beyond the brain midline — getting to places we couldn’t reach before.” For the partnership of otolaryngology with neurosurgery, the future is now.
Thanks to a rare endoscopic surgical procedure that brought an end to months of painful, debilitating nose bleeds and prevented serious facial deformities, a 12-year-old boy can return to a normal life.
New endoscopic techniques combining the expertise of Mark Shikowitz, MD, vice chairman of the Long Island Jewish (LIJ) Medical Center Department of Otolaryngology, and David Siegel, MD, chief of LIJ’s Division of Vascular and Interventional Radiology, led to the safe removal of a juvenile angio fibroma. These are vascular (blood vessel) tumors that occur almost exclusively in adolescent males. The most common symptom is recurrent nosebleeds with nasal obstruction. In addition, erosion of the surrounding bone can occur. If left untreated, the disease can cause facial deformity, proptosis (eyebulging) or blindness.
Doctors recommended surgery to remove the tumor or it would continue to grow. Previously, the majority of these tumors were removed through open surgery — an incision was made along the entire side of the nose and the nose flipped over to reach the affected area. In some cases, the entire face would be pulled from under the lip. These procedures leave a large scar extending from above the eye to the base of the nose.
Dr. Shikowitz and Dr. Siegel decided to use a surgical approach to remove the tumor through the nose without any cuts or incisions on the patient’s face. First, Dr. Siegel used special radiological services to embolize (block off) the tumor, to decrease blood loss during surgery. Once that process was completed, the tumor was successfully removed through the nose by Dr. Shikowitz with the latest endoscopic technique, leaving no scars on the patient.