severe deformity and neurologic deficits or neural compres-sion resulting from epidural abscess or granulation tissue,leading to a much better outcome than fusion or laminec-tomy alone.7,25

This patient demonstrates an unusual situation in whichesophageal rupture during endoscopy led to vertebral osteo-myelitis, discitis and epidural abscess with neurological deficit.Physicians need to be aware of this potential complication.Early diagnosis is a key factor to avoid neurologic sequelaein the treatment of patients with spinal infection.

References

1. Mamourian AC, Dickman CA, Drayer BP, et al. Spinal epiduralabscess: three cases following spinal epidural injection demonstratedwith magnetic resonance imaging. Anesthesiology 1993;78:204–7.

2. Strong WE. Epidural abscess associated with epidural catheterization:a rare event? Report of two cases with markedly delayed presentation.Anesthesiology 1991;74:943–6.

3. Del Curling Jr O, Gower DJ, McWhorter JM. Changing concepts inspinal epidural abscess: a report of 29 cases. Neurosurgery 1990;27:185–92.

4. Go BM, Ziring DJ, Kountz DS. Spinal epidural abscess due toAspergillus sp in a patient with acquired immunodeficiency syndrome.South Med J 1993;86:957–60.

5. Calderone RR, Larsen JM. Overview and classification of spinalinfections. Orthop Clin North Am 1996;27:1–8.

6. Samuel W, Dryden M, Sampson M, et al. Spinal abscess ofHaemophilus paraphrophilus. A case report. Spine 1997;22:2763–5.

7. Hadjipavlou AG, Mader JT, Necessary JT, et al. Hematogenouspyogenic spinal infections and their surgical management. Spine

2000;25:1668–79.8. Frot-Martin B, Carlier RY, Morand-Blot V, et al. Zenker’s diverticulum

associated with multilevel cervical osteomyelitis. Spine 2001;26:E193–7.9. Lehman CR, Deckey JE, Hu SS. Eikenella corrodens vertebral

osteomyelitis secondary to direct inoculation: a case report. Spine

2000;25:1185–7.

10. Osenbach RK, Hitchon PW, Menezes AH. Diagnosis and manage-ment of pyogenic vertebral osteomyelitis in adults. Surg Neurol

1990;33:266–75.11. Mattingly WT, Dillon ML, Todd EP. Cervical osteomyelitis after

esophageal perforation. South Med J 1982;75:626–7.12. Silvis SE, Nebel O, Rogers G, et al. Endoscopic complications.

Results of the 1974 American Society for Gastrointestinal EndoscopySurvey. JAMA 1976;235:928–30.

13. Fernandez FF, Richter A, Freudenberg S, et al. Treatment ofendoscopic esophageal perforation. Surg Endosc 1999;13:962–6.

14. Ajalat GM, Mulder DG. Esophageal perforations. The need for anindividualized approach. Arch Surg 1984;119:1318–20.

15. Wilde PH, Mullany CJ. Oesophageal perforation–a review of 37 cases.Aust NZ J Surg 1987;57:743–7.

16. Wesdorp IC, Bartelsman JF, Huibregtse K, et al. Treatment ofinstrumental oesophageal perforation. Gut 1984;25:398–404.

17. Bonfiglio M, Lange TA, Kim YM. Pyogenic vertebral osteomyelitis.Disk space infections. Clin Orthop 1973;96:234–47.

18. Digby JM, Kersley JB. Pyogenic non-tuberculous spinal infection: ananalysis of thirty cases. J Bone Joint Surg Br 1979;61: 47–55.

19. Jones NS, Anderson DJ, Stiles PJ. Osteomyelitis in a general hospital.A five-year study showing an increase in subacute osteomyelitis. J

Bone Joint Surg Br 1987;69:779–83.20. Kemp HB, Jackson JW, Jeremiah JD, et al. Pyogenic infections

occurring primarily in intervertebral discs. J Bone Joint Surg Br

1973;55:698–714.21. Wood GWI. Infection of the Spine. In: Canale ST, editor. Campbell’s

Operative Orthopaedics. 10 edn. St. Louis: Mosby Inc; 2003. p. 2030–40.22. Modic MT, Masaryk TJ, Weinstein MA. Magnetic resonance imaging

of the spine. Magn Reson Annu 1986:37–54.23. Emery SE, Chan DP, Woodward HR. Treatment of hematogenous

pyogenic vertebral osteomyelitis with anterior debridement andprimary bone grafting. Spine 1989;14:284–91.

24. Stone JL, Cybulski GR, Rodriguez J, et al. Anterior cervicaldebridement and strut-grafting for osteomyelitis of the cervical spine.J Neurosurg 1989;70:879–83.

25. Rath SA, Neff U, Schneider O, et al. Neurosurgical management ofthoracic and lumbar vertebral osteomyelitis and discitis in adults: areview of 43 consecutive surgically treated patients. Neurosurgery

1996;38:926–33.

doi:10.1016/j.jocn.2006.02.023

Pituitary abscess in a pregnant woman

Hyo-Chang Kim, Seok-Gu Kang *, Pil-Woo Huh, Do Sung Yoo,Kyoung Suok Cho, Dal Soo Kim

Department of Neurosurgery, The Catholic University of Korea College of Medicine, Uijeongbu St. Mary’s Hospital, 65-1 Kumohdong,

Uijeongbu, Gyeonggi 480-130, Republic of Korea

Received 2 January 2006; accepted 7 March 2006

Abstract

Pituitary abscess is a rare and potentially lethal condition. Pituitary abscess in a pregnant woman has not been previously described. A38-year-old pregnant woman (34 weeks gestation) with a pituitary mass complained of a progressive headache and sudden visual impair-

* Corresponding author. Tel.: +82 31 820 3638; fax: +82 31 846 3117.E-mail address: seokgu9@kornet.net (S.-G. Kang).

Case Reports / Journal of Clinical Neuroscience 14 (2007) 1135–1139 1135

ment. She was afebrile and had no inflammatory symptoms on admission. On MRI, the preoperative diagnosis was pituitary adenomawith sphenoid sinusitis. She underwent an uncomplicated transsphenoidal procedure for removal of the pituitary mass. The next day,labor commenced and a healthy preterm baby was delivered. Pathologic examination of the intrasellar mass showed polymorphonuclearcells, debris and no tumor cells. The sellar contents were cultured and Streptococcus viridans was grown. To our knowledge this is the firstcase of pituitary abscess reported during pregnancy. Although the patient was pregnant, the transsphenoidal approach was safe for themother and the fetus. Surgical drainage and antibiotic therapy are required for the definitive treatment of this condition.� 2006 Elsevier Ltd. All rights reserved.

Keywords: Fetus; Pituitary abscess; Pregnancy; Transsphenoidal approach

1. Introduction

Since pituitary abscess was first described in 1914,1 therehave been many reports of this disease.2–5 The normal pitu-itary gland may enlarge by as much as 50–70% during preg-nancy.6 It is well known that pregnancy may also promotefurther growth of pre-existing pituitary adenomas;7,8 how-ever, a pregnant patient presenting with pituitary abscess israre. On a review of the literature we found no other casesof pituitary abscess diagnosed during pregnancy. We re-port here a 38-year-old pregnant woman with a pituitaryabscess, treated by transsphenoidal decompression.

2. Case report

A 38-year-old, 30-weeks pregnant woman had experi-enced a headache, which began during the 26th week ofher third pregnancy. Until then, her pregnancy had beenuncomplicated, and her previous medical history was unre-markable. The patient did not complain of fever, nausea,vomiting or any other symptoms that may have suggestedan infectious process. She did not report any symptoms ofsinus infection and there were no meningeal signs.

The serum biochemistry was unremarkable and theperipheral blood count revealed a normal white blood cellcount (4.8 · 109/L) with 60.7% neutrophils. The first oph-thalmologic examination during the 30th week of gestationdocumented normal visual acuity (VA) of 1.0 in the righteye and 1.0 in the left, and perimetry revealed no visualfield (VF) deficit (Fig. 1a).

MRI showed an a 2.5 · 2.0 · 1.7 cm peripherally enhanc-ing and central low signal intensity mass in the sellar andsuprasellar cisterns (Fig. 2a). The suprasellar mass was com-pressing the optic chiasm (Fig. 2b). This mass encased thecavernous portion of the right internal carotid artery. A nor-mal pituitary gland was not seen. Mucoperiosteal thickeningwas noted in the sphenoid sinus. A pituitary macroadenomawith sphenoidal sinusitis seemed to be the most likely diag-nosis however the differential diagnosis would include pitu-itary abscess with sphenoidal sinusitis.

The serum prolactin concentration was within normalvalues for the 30th week of gestation (36.08 ng/mL), so thisfinding excluded a prolactinoma. There were also normalvalues for thyroid stimulating hormone, T3, T4, cortisol,follicle stimulating hormone, luteinizing hormone andgrowth hormone.

The obstetric team was reluctant for the patient to un-dergo pituitary surgery as the fetus was small (less than5th percentile) for gestational age and the patient’s head-ache could be controlled with analgesics. There was a pos-sibility that the viability of the fetus would be poor ifsurgery precipitated labor at this stage of development.

Fig. 1. The preoperative (a) follow-up (b) and postoperative (c) visual fields(VF). The patient’s VA (1.0/1.0) and VF in the 30th week of her pregnancywere normal. However, sudden deterioration of the VA (0.8/0.1) and VFwere observed during the 34th week of her pregnancy. After surgicaldecompression, her VA (1.0/0.9) and VF were well recovered.

1136 Case Reports / Journal of Clinical Neuroscience 14 (2007) 1135–1139

We decided to delay surgery. No antibiotics wereadministered for the sphenoidal sinusitis to avoid harmto the fetus.

Four weeks later, there was rapid deterioration of thepatient’s VA (0.8/0.1 compared with 1.0/1.0) and VF(Fig. 1b) and her severe headaches indicated that surgicaldecompression of the optic chiasm could not be delayedany longer. Using the transsphenoidal approach (TSA),selective microsurgical removal of the lesion was per-formed. There was some evidence of inflammatory mucosaldisease in the sphenoid sinus and the bony sellar floor wasvery thin. After removal of the floor, the dura was found tobe very thick and under tension. The dura was incised andsignificant amounts of whitish-yellow purulent materialcame out under pressure. After performing complete evac-uation and irrigation, normal gland tissue was observed.The preoperative and perioperative obstetric examinations

were normal, including intraoperative monitoring of thecardiotocogram. Intraoperative and postoperative feno-terol was used to prevent premature labor.

Pathologic examination of the capsule showed a mixtureof neutrophils and lymphocytes in the granulation tissuewith microhemorrhage (Fig. 3), indicating the abscess wall.There was also no evidence of pituitary adenoma. The sel-lar contents were cultured separately from the mucosalcontents of the sphenoidal sinus and Streptococcus viridans

was grown. Stains for acid fast bacilli were negative. Addi-tionally, no organisms were cultured from the mucosalcontents of the sphenoidal sinus.

The morning after TSA, the patient went into labor. Shehad an emergency C-section and delivered a health baby(1.83 kg), with Apgar scores of 5 and 7 at 1 and 5 minutesrespectively. The patient was treated with intravenous anti-biotics (ceftriaxone 1 g 12-hourly, and amikacin 450 mg 12-hourly) for 6 weeks after her surgery. The postoperativecourse was uneventful except for mild, transient diabetesinspidus. The VA improved to 1.0/0.9 compared with0.8/0.1 and the VF defect completely resolved (Fig. 1c)over the next few weeks. No signs of pituitary insufficiencywere present upon her discharge from the hospital. Sixmonths after surgery she was symptom free.

3. Discussion

The normal pituitary gland enlarges during pregnancy,and this predominantly occurs because of the estrogen-stimulated hyperplasia of the prolactin-producing lacto-tropes.9,10 Molitch conducted a literature search to identifythe effect of pregnancy on pre-existing pituitary tumors andthe effect on the outcome of pregnancy due to hormoneoversecretion by pituitary tumors.6 Pregnancy may causean increase in the size of tumors that secrete prolactin, par-ticularly macroadenomas.6 However, the effects of preg-nancy on pre-existing pituitary abscess are not known.Our patient’s fetus was small (less than 5th percentile) for

Fig. 2. Preoperative sagittal (a) and coronal (b) T1-weighted MRI showing the intra-sellar and suprasellar space-occupying lesion distorting the opticchiasm. The peripheral portion of this mass is well enhanced.

Fig. 3. Examination of the biopsied tissue capsule shows a mixture ofpolymorphonuclear leukocytes and lymphocytes in the granulation tissuewith microhemorrhage. There was no adenoma (H&E stain, ·200).

Case Reports / Journal of Clinical Neuroscience 14 (2007) 1135–1139 1137

gestational age, which meant that intrauterine growthretardation may have occurred, although the delivery andthe condition of the fetus were ultimately good.

Most pituitary abscess patients present with symptomsand signs of meningitis or pituitary neoplasm.11–13 Themost common etiologic factors are sphenoid sinusitis, men-ingitis, pituitary neoplasm and inflammatory or granulom-atous disease such as tuberculosis, sarcoidosis orsyphilis.11–13 Our patient had no evidence of meningitisor any other infectious process; however, she had sphenoidsinusitis as the definable source of the infection.

Although the MRI findings of pituitary abscesses havebeen reported,14–17 the preoperative diagnosis is quite diffi-cult, even with MRI, which show non-specific cystic lesions.The presence of an intrasellar expansive lesion with a liquidcenter and a contrast-enhanced outline suggests an abscess,particularly when this is associated with sphenoid sinus effu-sion.16 Our patient had sphenoid sinusitis on MRI (Fig. 1a)and also a contrast-enhanced cystic sellar and suprasellarmass, which could suggest pituitary abscess. However, weinitially diagnosed a pituitary macroadenoma with repeatedmicro-hemorrhage and sphenoidal sinusitis. The postopera-tive diagnosis was pituitary abscess, which has the same ini-tial treatment as for pituitary macroadenoma.

If a pregnant woman with a pituitary mass experiencesheadaches and loss of vision, then lymphocytic hypophysi-tis has to be considered in the differential diagnosis, as pre-viously reported.18–23 However, our patient had purulentmaterial that grew S. viridans, excluding lymphocytichypophysitis. Cultures of pus reveal bacteria or fungi asthe causative agents in about 50% of cases,4,11,24,25 andthe most common infectious agents are Gram-positivecocci.2,26–28

Rathke’s cleft cysts (RCC) with purulent contentsshould be considered as a differential diagnosis.29 We hadto consider this possibility contaminated by the sphenoidsinusitis, as we did not use any antibiotics until the TSA.However, our patient was confirmed to have an abscessrather than RCC because there were no specific micro-scopic findings consistent with RCC,30,31 typically a singlelayer of squamous, cuboidal, or globlet cell epithelium on athin connective tissue layer.

If pituitary abscess is diagnosed preoperatively, thenTSA is considered the best approach as it avoids contami-nation of the cerebrospinal fluid, it provides a route forprolonged drainage of the infected area, it allows properdecompression of the optic chiasm, and it helps manageany associated sinusitis.4,12,25 Antibiotic therapy shouldbe initiated as soon as the diagnosis of pituitary abscessis confirmed during surgery for the patient who exhibitsthe symptoms of sepsis.4,32

Based on our first experience with a pituitary abscess ina pregnant woman, this disease may disturb the develop-ment of the fetus. Thus, especially for pregnant women,as soon as a pituitary abscess is suspected, we strongly rec-ommend performing immediate TSA, followed byantibiotics.

References

1. Simmonds M. Ueber embolische prozesse in der hypophysitis. Arch

Pathol Anat 1914;217:226–39.2. Jain KC, Varma A, Mahapatra AK. Pituitary abscess: a series of six

cases. Br J Neurosurg 1997;11:139–43.3. Hanel RA, Koerbel A, Prevedello DM, et al. Primary pituitary

abscess: case report. Arq Neuropsiquiatr 2002;60:861–5.4. Vates GE, Berger MS, Wilson CB. Diagnosis and management of

pituitary abscess: a review of twenty-four cases. J Neurosurg

2001;95:233–41.5. Hon CS, Knuckey N, Robbins P, et al. Pituitary abscess. J Clin

Neurosci 1999;6:351–3.6. Molitch ME. Pituitary tumors and pregnancy. Growth Horm IGF Res

2003;13 (Suppl.A):S38–44.7. Bevan JS, Burke CW, Esiri MM, et al. Misinterpretation of prolactin

levels leading to management errors in patients with sellar enlarge-ment. Am J Med 1987;82:29–32.

8. Johnson Jr RJ, Voorhies RM, Witkin M, et al. Fertility followingexcision of a symptomatic craniopharyngioma during pregnancy: casereport. Surg Neurol 1993;39:257–62.

9. Goluboff LG, Ezrin C. Effect of pregnancy on the somatotroph andthe prolactin cell of the human adenohypophysis. J Clin Endocrinol

Metab 1969;29:1533–8.10. Scheithauer BW, Sano T, Kovacs KT, et al. The pituitary gland in

pregnancy: a clinicopathologic and immunohistochemical study of 69cases. Mayo Clin Proc 1990;65:461–74.

11. Bjerre P, Riishede J, Lindholm J. Pituitary abscess. Acta Neurochir

(Wien) 1983;68:187–93.12. Domingue JN, Wilson CB. Pituitary abscesses. Report of seven cases

and review of the literature. J Neurosurg 1977;46:601–8.13. Har-El G, Swanson RM, Kent RH. Unusual presentation of a

pituitary abscess. Surg Neurol 1996;45:351–3.14. Takahashi T, Shibata S, Ito K, et al. Neuroimaging appearance of

pituitary abscess complicated with close inflammatory lesions–casereport. Neurol Med Chir (Tokyo) 1998;38:51–4.

15. Abs R, Parizel PM, Verlooy J, et al. Magnetic resonance character-ization of a long-standing pituitary abscess. J Endocrinol Invest

1993;16:635–7.16. Bossard D, Himed A, Badet C, et al. MRI and CT in a case of

pituitary abscess. J Neuroradiol 1992;19:139–44.17. Dickob M, Scharphuis T, Distelmaier P, et al. Diagnosis of

hypophyseal abscess using MRI and high resolution CT. Neurochirur-

gia (Stuttg) 1989;32:184–6.18. Sautner D, Saeger W, Ludecke DK, et al. Hypophysitis in surgical and

autoptical specimens. Acta Neuropathol (Berl) 1995;90:637–44.19. Kerrison JB, Lee AG, Weinstein JM. Acute loss of vision during

pregnancy due to a suprasellar mass. Surv Ophthalmol 1997;41:402–8.20. Alexiadou-Rudolf C, Hildebrandt G, Schroder R, et al. Lymphocytic

adenohypophysitis mimicking a pituitary macroadenoma. Neurosurg

Rev 2000;23:112–6.21. Flanagan DE, Ibrahim AE, Ellison DW, et al. Inflammatory hypoph-

ysitis – the spectrum of disease. Acta Neurochir (Wien) 2002;144:47–56.22. Vizner B, Talan-Hranilovic J, Gnjidic Z, et al. Lymphocytic adeno-

hypophysitis simulating a pituitary adenoma in a pregnant woman.Coll Antropol 2002;26:641–50.

23. Hartmann I, Tallen G, Graf KJ, et al. Lymphocytic hypophysitissimulating a pituitary adenoma in a nonpregnant woman. Clin

Neuropathol 1996;15:234–9.24. Lindholm J, Rasmussen P, Korsgaard O. Intrasellar or pituitary

abscess. J Neurosurg 1973;38:616–9.25. Nelson PB, Haverkos H, Martinez AJ, et al. Abscess formation

within pituitary tumors. Neurosurgery 1983;12:331–3.26. Robinson B. Intrasellar abscess after transsphenoidal pituitary

adenomectomy. Neurosurgery 1983;12:684–6.27. Sahjpaul RL, Lee DH. Infratentorial subdural empyema, pituitary

abscess, and septic cavernous sinus thrombophlebitis secondary to

1138 Case Reports / Journal of Clinical Neuroscience 14 (2007) 1135–1139

paranasal sinusitis: case report. Neurosurgery 1999;44:864–6, discus-sion 866–8.

28. Gatell JM, Esmatjes E, Serra C, et al. Diabetes insipidus and anteriorpituitary dysfunction after staphylococcal meningitis and multiplebrain abscesses. J Infect Dis 1982;146:102.

29. Maartens NF, Ellegala DB, Lopes MB. Pituitary abscess. J Neurosurg

2001;95:1110–2.

30. HamaS,AritaK,NishisakaT,et al. Changes in the epithelium ofRathkecleft cyst associated with inflammation. J Neurosurg 2002;96:209–16.

31. Kleinschmidt-DeMasters BK, Lillehei KO, Stears JC. The pathologic,surgical, and MR spectrum of Rathke cleft cysts. Surg Neurol

1995;44:19–26, discussion 7.32. Gokalp HZ, Deda H, Baskaya MK, et al. Pituitary abscesses. Report

of three cases. Neurosurg Rev 1994;17:199–203.

doi:10.1016/j.jocn.2006.03.012

Airway obstruction after extubation following use of transesophagealechocardiography for posterior fossa surgery in the sitting position

Mihir Prakash Pandia *, Parmod Kumar Bithal, Hemant Bhagat, Munish Sharma

Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, Ansarinagar, New Delhi 110 029, India

Received 2 October 2005; accepted 27 November 2005

Abstract

We report respiratory obstruction following surgery in the sitting position with tracheal intubation and placement of a transesoph-ageal echocardiography probe. Obstruction was due to pharyngeal oedema, which resolved with 24 hours. The mechanisms of this com-plication are discussed.� 2005 Elsevier Ltd. All rights reserved.

Keywords: Respiratory obstruction; Sitting position; Tran esophageal echocardiography

1. Introduction

Respiratory obstruction following surgery in the sittingposition occurs because of oedema of the pharyngeal struc-tures, including the soft palate, pharyngeal wall and base ofthe tongue.1 Trauma associated with presence of an artifi-cial airway and excessive neck flexion compounded bylengthy procedures, is usually implicated as the cause ofswelling of these structures and subsequent complications.

Transesophageal echocardiography (TEE) is the mostsensitive monitor for early detection of venous air embo-lism during neurosurgical procedures performed in the sit-ting position.2 However, insertion and manipulation of aTEE probe may lead to a variety of complications.3–10

Trauma associated with insertion and maneuvering of aTEE probe may predispose a patient to develop airwayswelling while in the sitting position.

We report a patient with respiratory obstruction causedby pharyngeal swelling associated with the use of a TEEprobe during posterior fossa surgery in the sitting position.

2. Case report

A 33-year-old man weighing 52 kg, with a recurrent cere-bellar astrocytoma was scheduled for midline suboccipitalcraniotomy and tumor excision in the sitting position. Hehad no other associated illnesses. He was fully conscious,oriented and had intact lower cranial nerves. Airway exam-ination revealed a Mallampati grade II airway and no intra-oral or pharyngeal pathology. He was premedicated with5 mg diazepam orally the previous night and glycopyrrolate0.2 mg intramuscularly before being transported to the oper-ation theatre. After standard monitors were placed thepatient was induced with 100 lg fentanyl, 300 mg thiopen-tone and the trachea was intubated with a 34 FG armouredtube following admistration of 70 mg rocuronium. Anaes-thesia was maintained with 66% N2O in O2, isoflurane andadditional doses of fentanyl and rocuronium. After trachealintubation a lubricated TEE probe (MPT7-4, diameter ofdistal tip 9.27 mm; Philips Medical Systems, Bothell, WA,USA) was inserted into the esophagus with the aid of a laryn-goscope. Resistance was encountered during the insertion ofthe TEE probe and several attempts were made before suc-cessful insertion of the probe was achieved. A mouth gagdesigned to prevent bite on the TEE probe was placed. No

* Corresponding author. Tel.: +91 11 26593474; fax: +91 11 26588663.E-mail address: mihirpandia@yahoo.co.in (M.P. Pandia).

Case Reports / Journal of Clinical Neuroscience 14 (2007) 1139–1141 1139