by Michelle Gurel BSN & Karen JP Liebert BSN RN
NEPTCC Newsletter Volume 22, Issue 1, Fall 2015 [PDF version]
WHAT IS TRANSSPHENOIDAL PITUITARY SURGERY?
This is a neurosurgical procedure typically used to remove
pituitary tumors. It is important that the operation be done
by someone who is expert in the procedure, performing it on
a regular basis, as this provides the best chance to remove
the tumor while leaving the normal pituitary gland in place.
The pituitary gland is located at the base of the brain and
behind the bridge of the nose. The easiest access to the
pituitary region is via a transsphenoidal approach. With
this approach, an operative microscope or endoscope and
surgical instruments are inserted in the nasal cavity (or
less commonly, under the upper lip and through the upper
gum) and a small incision is made in the bone behind the
nasal cavity. Behind this opening is an air cavity, called the
sphenoid sinus. The surgical tools are passed through the
sphenoid sinus to an area directly behind the sphenoid sinus
into the bony cavity of the sella turcica. The pituitary gland is
located within the sella turcica.
HOW LONG DOES THE OPERATION TAKE?
The procedure itself usually takes about three hours.
Following surgery, patients will usually spend about two
to three hours in the recovery room and are then admitted
to the hospital floor. There is usually no need to stay in an
Intensive Care Unit. Most patients are discharged from
the hospital one or two days following surgery. In certain
circumstances, such as in a patient with another medical
condition, or if there is a complication,
the stay may be longer.
HOW WILL I FEEL RIGHT AFTER THE SURGERY?
The most frequent symptoms after surgery are a sinus
headache, nasal congestion and mild fatigue, which will
gradually improve over a few weeks
COMMON QUESTIONS ABOUT SYMPTOMS AFTER TRANSSPHENOIDAL SURGERY ARE:
WHAT DO I NEED TO KNOW ABOUT HEADACHES & NECK
PAIN AFTER TSS?
It is normal to experience headaches after pituitary surgery.
If headaches worsen or are unrelieved by over-thecounter
pain medication, you should notify your physician/
neurosurgeon. If your neck feels stiff and is painful, you
should notify your physician/neurosurgeon immediately.
WHAT IF I NEED TO SNEEZE/COUGH AFTER TSS?
If you need to sneeze or cough during the first week or two
after surgery, you should stay relaxed and let it happen.
Don’t hold your breath or pinch your nose. Avoid things that
make you sneeze like dust, animal dander, and cigarette
smoke. You should gently clear your nose initially. After
three days, you can gently blow your nose.
WILL I HAVE SINUS CONGESTION?
Sinus congestion is normal and may persist for up 3 to 4
weeks after pituitary surgery. Nasal decongestants can
be used anytime and saline is okay after the first week. If
you think you have a sinus infection, you should notify your
WHAT IF I EXPERIENCE NASAL DRAINAGE?
It is normal to have mucous or drainage that is dark redbrown
or maroon in color. However, clear fluid, like
water dripping from a faucet, or a lot of bright red blood,
is not normal and you should notify your physician/
WHAT SHOULD I KNOW ABOUT NOSE BLEEDS?
Spotting of red blood, or bloody mucous, from the nose is
normal. Brisk bleeding from the nose rarely occurs. The
most common cause of a nose bleed is from a small vessel
in the nose (not bleeding from the tumor or brain). As with
all nose bleeds, apply gentle pressure to stop the bleeding.
If this does not control the bleeding, then go to your local
emergency room and ask them to notify your physician/
WHAT SHOULD I DO IF I HAVE A FEVER?
If the fever is higher than 101°F, double the dose of steroids
(prednisone/hydrocortisone), if you are are taking this type of
medication, until the fever subsides. If during the first two
weeks after surgery, the fever goes above 101°F, notify your
CAN I DO BENDING & LIFTING OR WORK-OUT/EXERCISE?
During the first two weeks, avoid bending and do not lift more than 20 pounds.
After four weeks, most patients can return to strenuous exercise.
WHEN WILL I BE ABLE TO?
- DRIVE, FLY,
- TWO WEEKS
- RETURN TO WORK
(GENERALLY, CONSULT PHYSICIAN)
- FOUR WEEKS
- GO ON AMUSEMENT PARK RIDES
(LIKE A ROLLER COASTER)
FAQS SPECIFIC TO TRANSSPHENOIDAL SURGERY FOR CUSHING’S DISEASE
WHAT WILL IMPROVE IF I AM IN REMISSION AFTER TSS?
In most patients, the physical and emotional problems
associated with Cushing’s disease improve and may resolve
over the one to two years after remission.
IS THERE ANYTHING I CAN DO TO HELP WITH WEIGHT
LOSS IF I AM IN REMISSION AFTER TSS?
Eating a healthy, well-balanced diet, limiting portion size
and/or calories will help you lose weight once your cortisol
levels are controlled. Lowering the steroid (prednisone/
hydrocortisone) replacement dose according to your
endocrinologist’s instructions will also help. A gradually
increasing program of exercise can contribute to weight loss,
stamina and muscle strength.
HOW SOON WILL I FEEL BETTER AFTER TSS PUTS ME IN
REMISSION FROM CUSHING’S DISEASE?
At first, patients may feel worse, rather than better, because the fall in cortisol can be associated with aches and fatigue. It is important to work closely with your endocrinologist to adjust your steroid (prednisone/hydrocortisone) dose so that you can be on the lowest dose that is safe for you (higher doses than you need can delay the recovery).
WHAT IS THE CHANCE OF THE
CUSHING’S DISEASE COMING BACK?
Most patients do not experience a recurrence of Cushing’s disease, but it is important to know that this can eventually happen in about 10-25% of patients.
A recurrence may develop as early as six or 12 months after TSS, but can also take place after more than 25 years. For this reason, it is essential to remain under the care of an endocrinologist. You should see an endocrinologist soon after having transsphenoidal surgery and for routine followup visits on a regular basis. You should discuss with your endocrinologist any concerns that the Cushing’s disease might be returning.
WHAT IF I EXPERIENCE A RECURRENCE
OF CUSHING’S DISEASE?
There are many good treatments available for patients who have a recurrence, including surgery, a number of medications and radiation (often given along with medication). Talk with your endocrinologist if you experience a recurrence.
WHAT IF MY CORTISOL LEVELS REMAIN ELEVATED AFTER SURGERY?
It is very important that cortisol levels be controlled to prevent the long-term complications of Cushing’s disease. If this is
not possible with surgery alone, further treatment is needed. There are many treatments available for patients who are not in
remission after TSS. Talk with your endocrinologist about these options to find the one that is right for you.
FAQS SPECIFIC TO TRANSSPHENOIDAL SURGERY FOR ACROMEGALY
WILL THE CHANGES IN MY BODY RETURN TO THE WAY
THEY WERE BEFORE I HAD ACROMEGALY?
While bony changes will not return to normal, soft tissue
swelling in the face, hands and feet can improve significantly.
Rings and shoes may become loose and facial changes
HOW QUICKLY MIGHT I SEE CHANGES IN MY
BODY AFTER TSS?
Some patients experience very rapid improvement in soft
tissue swelling as the levels of growth hormone fall after
surgery, and may feel their rings and shoes getting looser
within days. In other patients, the improvement may be
COULD THERE BE IMPROVEMENT IN MEDICAL
CONDITIONS SUCH AS DIABETES AND HYPERTENSION
(HIGH BLOOD PRESSURE) AFTER TSS?
When growth hormone is lowered/controlled, medical
conditions, such as diabetes and hypertension, may improve
and even resolve. In some patients with diabetes, blood
sugar may fall quickly, so that it is important to talk with the
doctor treating your diabetes to learn whether a reduction in
any medications is advised. Similarly, in patients with high
blood pressure, a reduction in medications may be needed
if blood pressure improves. Be sure to discuss this with the
doctor who prescribes your blood pressure medications.
WHAT IF MY GROWTH HORMONE LEVELS REMAIN ELEVATED AFTER SURGERY?
It is very important that growth hormone levels, and the hormone called insulin-like growth hormone (IGF-I) be controlled,
to prevent the long-term complications of acromegaly. If this is not possible with surgery alone, further treatment is needed.
There are several types of medications available to treat acromegaly if a patient is not cured by surgery. Somatostatin analogs
and a GH receptor antagonist (both given by injection) are the most commonly used medications. In mild cases, a dopamine
agonist, which is given in pill form, may be tried. Sometimes these medications are used in combination. Discuss the many
treatment options with your endocrinologist.