Pituitary Innovation and Teaching Videos

Speaker: Dr. Jeannette Goguen, endocrinologist

Video transcript

There are three types of problems that can arise if you have a tumour in your pituitary.

The first one is called mass effect and that has to do with problems arising from the size of the tumours; these tumours are typically very tiny but they’re large enough to cause problems in the brain because of the area that they’re growing in is very small and there’s all sorts of critical structures surrounding them, particularly the nerves to the eyes. The patient may complain of headaches and may complain of visual disturbances that’s why its particularly important to have follow up with regular MRIs to assess if the tumour is growing, regular appointments with your eye doctor, and visual field testing.

The second problem is if there is overproduction of pituitary hormones. This is not that common. The commonest version of this is when prolactin is overproduced that can cause milk production for a female, throws off their periods, causes infertility. For the males it can cause low libido or low sex drive and cause problems with erections and problems with fertility as well. The second problem, which is quite rare, is overproduction of growth hormone that causes a disease called acromegaly. And what happens is patients notice their hands and feet are growing, their facial features are changing and there’s a whole series of other manifestations. The third with over production of ACTH is called Cushing’s disease. And this is as well is rare, but very disturbing for patient. They will gain a lot of weight particularly around the middle, their facial features will change. Problems with bruising, weakness, all sorts of issues that are very disruptive for the patient and can cause serious medical conditions associated with it.

The third type of problem is underproduction. I have already told you there are seven hormones made in the pituitary. each of these can be underproduced if the growth that is happening is disturbing normal pituitary function. this can lead to low acth. so the patient feels very tired, weak, weight loss. It can lead to low TSH affecting the thyroid so the patient develops symptoms of under-active or hypothyroidism and can lead to weight gain, feeling cold, feeling tired, constipation, dry skin. If LH and FSH are disturbed patients can have problems similar to the high prolactin levels where the sexual function is disturbed. Problems with growth hormone are particularly a concern for children because they don’t achieve their regular adult height, they stop growing. ADH is more of a problem after surgery, we’ll talk about that later.

So when you are sent to see me, I will assess for mass affect, for pituitary hormone over production, and pituitary hormone under production. So there’s lots of blood tests, lots of physical exam manoeuvres and such to see if any of these are a problem. As well, if you have Cushing’s disease or acromegaly, this can affect a lot of other parts of the body and we have to assess for things like diabetes, hypertension, heart disease. So there’s a fair bit of work getting sorted out to make sure that we can get you back to normal.

Speaker: Dr. Michael Cusimano

Video transcript

Prolactin is a hormone that is normally produced when a woman is pregnant and it allows the breast milk to come down when the baby cries. If there is a excessive growth of the in the pituitary gland that produces this prolactin hormone, person will develop what’s called a prolactinoma. And in women often the cardinal sign is that their period will stop, or it may become very irregular and they may develop breast milk. And they may not be able to conceive because the body has been fooled, kind of like it’s pregnant. And these would be the commonest kind of tumors.

In men we don’t have a great understanding of what prolactin does but some men do see sexual dysfunction or loss of sex drive. But very often the tumors in men that produce prolactin will grow to a fairly large size before they produce symptoms and the commonest way that men present with these tumors is with headaches and with pressure on the eye nerves that allow us to see, so they will be losing their vision. So those are the commonest ways that men present.

Speaker: Dr. Michael Cusimano

Video transcript

The second commonest tumor that we see – the tumors produce growth hormone and if this occurs in childhood before the bones are fused, we see children grow to very tall heights – so called giants and the condition is called Gigantism. Fortunately that’s rare but it does occur.

More commonly it occurs after the bones have stopped their growth spurt and what we see is that the bones get thicker throughout the body and so you can get enlargement of the fingers or the feet or the hands. These become very large. You can get a forehead becoming prominent, the jaw becoming prominent, the nose becoming prominent. Because the jaw gets larger the teeth can spread apart and then not only do the bones get larger but the soft tissues, the skin and the underlying tissues get larger. The tongue can get larger, people can snore, they can gasp for breath or what is called sleep apnea and the internal organs get bigger too. So the heart will get larger, it can lead to pre-mature heart attacks. Polyps can grow in the colon etc. They can get skin tags, excessive sweating.

This condition is called Acromegaly. Acro coming from the Greek for finger or digit. Megaly meaning big, so the digits get big. This condition and the others have been identified for hundreds of years by physicians and date back to the old times of the ancient writers.

Speaker: Dr. Michael Cusimano

Video transcript

Now the least common of the secreting kinds of tumors are tumors that produce a kind of hormone called ACTH. Now, ACTH acts on a gland called the adrenal gland which sits above the kidneys and the adrenal gland produces coritsol hormone. The cortisol hormone is an energy type hormone that is responsible for our daily metabolism.

Now if these tumors secrete too much of this hormone the commonest symptoms would be weight gain and particularly around the central girth. It would often cause hair growth on the face. It can cause disturbance in a woman of her menstrual period. It very commonly leads to emotional or even psychiatric problems – the commonest of these would be anxiety and depression. The weight gain can also be associated with a flushing of the face so that the cheeks become very red, face becomes rounded. You can develop deposits of fat at the back of neck or here – just above the collar bones. You can get stretch marks and they’re different than the stretch marks that are obtained in pregnancy in that they tend to be purplish in color as opposed to whitish. Can get darkening of the skin, particularly in the underarms.

You can get a whole series of symptoms associated with excessive cortisol production and this syndrome is called Cushing syndrome. And that’s the least common of the types of secreting tumors but it can be having very significant side effects. For example, people with Cushing syndrome or Cushing’s disease where the syndrome is caused by a tumor in the pituitary gland can develop very brittle diabetes. And with brittle diabetes heart disease can progress very rapidly, they can develop high blood pressure. They can die of things like premature heart attacks. So the prognosis with something like Cushing’s is about equal to that of breast cancer. So, we can need to treat those as well.

Video transcript

Introduction: My name is Dr. Irene Vanek. I am a neuro-ophthalmologist, and I am part of the pituitary team. That means I manage vision, and I work closely with the neurosurgeons involved with pituitary care.

Presurgical assessments: They need the whole team involved, which means the neurosurgical aspect with the neuro-imaging. They need the endocrinologist for the hormonal assessment, because only some tumours are what we call secreting tumours – most of the tumours are not. I, as a neuro-ophthalmologist, deal with those who have decline of the vision. Of course, I see some with perfectly normal vision, and yet they have pituitary tumour, but they all get basic screening in order to know how we should most effectively manage them.

Physiology of vision: The physiology of vision, which involves the pituitary tumour, consists of the visual impulse, or the visual signal, being collected from the retina and goes into the optic nerve, which is the first station. It then goes to the chiasm, and those 2 structures are the most important in evaluating the visual dysfunction in patients with pituitary tumour. The other pathways, or the other stations, in this visual pathway, are very important for vision. But the pituitary tumour usually involves the anterior chiasmatic pathway, which is the optic nerve and the chiasm.

Visual problems that pituitary patients encounter: It really varies from patient to patient – some patients notice nothing at all and they could have accidentally found the pituitary tumour due to other quests, or they may complain of dimming vision (sometimes they may think it is cataracts or other eye causes). Sometimes they actually notice decrease of visual field, usually on the side, and it can be present in one eye or in both eyes. Some patients can notice decrease of colour vision perception, which actually happens with any cause which involves optic nerve function. Some patients may have double vision, and those in particular may be the ones who have a haemorrhage in the pituitary tumour, which we call pituitary apoplexy. That is one of the causes when they come to the hospital and get investigated pretty quickly because they have other symptoms associated with it as well, such as headaches.

Pressure in the eye: If you have a patient who has a secreting tumour, they may have a higher pressure, and they get picked up quite easily because they have all the hormonal changes. The regular pituitary takes much longer to recognize the visual decline, but often they are diagnosed by eye specialists or by ophthalmologists with glaucoma. And what often happens is that the pituitary tumour gets missed. And so I would like to bring to everybody’s attention that certain amount of patients will have glaucoma and yet they have a pituitary tumor. And so when there is a patient with glaucoma, I generally prefer to do imaging to make sure there is nothing in the brain associated with it. I have seen quite a number of patients with a large pituitary tumour who were managed by eye people for glaucoma for years.

Treatments? From the visual point of view, my role is to establish exactly what visual function they have at the time of examination. The time of examination ideally would mean that they come pre-op. So I would do my clinical examination, and I will do visual field. I may do HRT, which is a scanning of the optic nerve head, and I establish to what degree the visual function is comprised because the tumour grows out of the pituitary fossa and has approximately 1cm to travel before it reaches the chiasm. And once it happens, there is a propensity for visual decline. And they may notice visual field changes, usually on the side of the visual field and we call that, when that happens, compressive optic neuropathy. And we generally recommend surgery.

After surgery? It’s been my experience, unless the optic nerve has been really severely compromised prior to surgery, most patients do actually notice improvement of the vision, which is really most gratifying. They can notice the first improvements few days after the surgery, but we won’t really know what is the end result of vision for approximately a year.

FAQ? People who come here are usually frightened, because, for their vision, which is quite understandable. I try to establish exactly where they are at and reassure them that we can do something to improve their vision. In most cases, that is indeed so.

So the aim of the evaluation is to establish, in summary, exactly what visual function they have pre-op, and then see them immediately post-op, and then to follow-up with them in frequent intervals with visual field and clinical evaluations in order to manage any changes that may happen or occur along the way.

Will vision worsen more if tumour recurs? Certain percentages of tumours do recur in variable amounts of time, and more often than not, because we are not able to completely remove the tumour for neurosurgical reasons. The role of a neuro-ophthalmologist is to do frequently enough the examinations and the visual field to catch the change as it is happening. In other words, don’t let the vision drop too much. On the other side of the coin, there is the issue that the optic nerve is damaged, and that means the perfusion, or what we call the blood supply, to the optic nerve, has suffered somewhere along the way, and the optic nerve is much more sensitive to any additional burden, which, say, the new tumour can produce. And hence, one has to be more pro-active than perhaps expected by other specialists. And therefore, frequent check-ups are really on the top of my list.

The reasonably frequent question that I get is “what are the chances of restoring vision or the found optic nerve damage? This is a very important question because I do tell the patient that they have optic nerve damage, one eye, both eyes, or one eye more than the other. And then they ask me what will happen to this after the surgery? There are two sides of the coin to this: anatomy of the optic nerve, which tells me how the optic nerve looks like. That’s the anatomy. So I will tell them, “yes , the optic nerve looks pale, in one eye or in both eyes”. And the other side of the coin is, “how does this pale optic nerve appearance translate into what the vision can do?” So the appearance of the optic nerve is the anatomy. The visual field and the vision, as such, is function. And those two have to be understood in its complexity in order to be able to give the patient a proper answer as to what we expect the vision to be after the surgery. So in other words, just to make it really simple, you can have a pale optic nerve and see nothing or you can have a pale optic nerve and see 20/20. The problem with the pale optic nerve is that after, say, you have a prolonged pituitary tumour that hasn’t been detected in time, the longer it stays there, the more damage it has the chance to produce both to the anatomy and the function. And then if you de-bulk the tumour, and then sometimes in the future, in whatever interval, they get a new tumour, which grows reasonably slowly (as most of them do), then once you have this damage to the optic nerve, this  optic nerve is more susceptible to trouble. And therefore, if I see them 6 months or2 years after surgery, and I am noticing any little change – decreased colour vision in particular. So I compare all the parameters of what I had in the previous examination, and I collect new data exactly of those same parameters, and any difference I see, I act upon. And the purpose is to make sure that with this particular damaged optic nerve, which is more susceptible, that they won’t have a rapid decline if we don’t interfere. So the most crucial question in any pituitary tumour management, from the visual point of view, is when to interfere. And that is what my role is.

Speaker: Dr. Michael Cusimano

Video transcript

We’ll have them fill out the routine administrative questionnaires and things that we do and then you’ll come in to see the doctor. If you’ve had an MRI done at another hospital, its best to have an MRI loaded into the hospital computer network before hand and so it will make things more efficient. This can be done on the third floor in the film library of the radiology department. They’ll ask you for your hospital identification number.

When you come in to see the doctor you may see a resident or fellow before seeing the neurosurgeon or the endocrinologist. These are doctors in training who will take a history that is the story – your story – or history of your medical illnesses and specifically about this particular condition and then a physical examination will be done. Your various tests, like your MRI, CAT scan, blood tests and visual tests will be reviewed and then a series of questions will be going back and forth between the doctors and the patient and their family or friends.

We’ll usually be able to come up with what’s called a working diagnosis which is the provisional diagnosis which the doctors will work with from that point forward. That diagnosis may change as more information is gathered, but based on that diagnosis a series options for treatment with then be discussed – both in terms of the goals of those various options, potential benefits and the potential risks.

A recommendation will be made in general to the patient. The patient will be given usually time to think about the diagnosis, to think about the various options and to come to a decision. Now, many patients will have already decided by the time they come because they will already have seen several specialists before they get to us and that’s perfectly acceptable as well. But very often we’ll give information and people will have some time to think about it.

Speaker: Dr. Michael Cusimano

Video transcript

Before they get to St. Michael’s Hospital to the pituitary centre they will normally have had an MRI done – which is a detailed examination of the brain to show us the different areas of the brain that might be affected by the tumor or abnormality in or around the pituitary gland. They’ll often have a CAT scan as well. They’ll often have a blood test that they will have completed. One of those blood tests should be done at eight o’clock in the morning because it assesses a hormone called cortisol, which is best assessed early in the morning.

As well, we normally routinely get a series of vision tests or eye tests and the commonest of these is called a visual field test – which is a test where the person will sit in front of a screen with a button and look for lights to flash and then they’ll have to indicate when they see the light flashing. This gives us a sense of how their peripheral vision is. Some patients will also get tests of their central vision with something called the visual evoke potential – which is an electrical test assessing how quickly the eye conducts electricity or the nerve from the eye, more accurately, conducts electricity. And may we also get a test called HRT or OCT which tells us about the thickness of the optic nerve and whether there has been any damage in the past in the optic nerve or the in scene that we’re used to see with. So these are the types of tests that people will have prior to coming to St. Michael’s Hospital.

Speaker: Dr. Michael Cusimano

Video transcript

After you get into the operating room a checklist will be run over with you with the staff to make sure everyone’ s on the same page. And so in this check list we’ll be going through again the consents, making sure your consent is there, making sure your X-ray films, that is your MRI and CAT scan is available, that your blood work is there. We will be probably putting on some devices on your legs which are like stockings that massage your legs and to allow the circulation of blood to continue during the operation.

And then the anesthesia will go over their various checklist items. For example, they’ll go over the equipment and tell their team that the equipment is ready and the nurse will go through their checklist items to say that all the equipment that we need to do the surgery is ready. Once that’s done, then the anesthesia doctor will start to put you off to sleep.

It’s usually a matter of 10 to 15 minutes before you’re off to sleep and then the work continue s and we will set up various navigation aids that we use, the GPS system while you sleep. When you’re off to sleep and we’re sure that the anesthetic is deep enough, your head will be placed in a clamp that holds your head very still while we do the surgery. Some patients do feel a bit of tenderness in four points where the four points of the clamp hold their head still and this allows us to do the surgery without the head moving during the operation.

The operation itself will last a variable amount of time, obviously depending on the particular patient’s tumor and circumstances, but it generally takes about an hour after you get off to sleep to before we start the actual operation. The ear, nose, and throat – our ENT doctor will do their part of the operation first – that generally lasts about another hour and then the neurosurgeon will take over and do the part of the surgery around the brain and that can take anywhere from 1 to 6 or 7 hours depending on the type of tumor and the type of work that needs to be done.

And then the area will be repaired – it will take about half an hour to get you awake again and then the patient will generally go to the recovery room or the post anesthetic care unit, which is on the same floor. And then the surgeons will go and meet with your family and friends or whoever has accompanied you or telephone them if they weren’t able to stay or they are not able to make it that day and let them know how things are going. From there you’ll be generally brought up to the ninth floor after an hour or two of the observation and you’ll stay on the ninth floor for that night and for two or three days afterwards.

When the person awakes from surgery, initially they’ll be a bit groggy from the anesthetic but once they regain full conscious they’ll realize that there is usually some packing in their nose and that packing will come out within hours or the next day generally. Um, and what is left in the nose is a plastic sheet on each side of the mid line of the nose and this is to prevent scar tissue. And those two plastic sheets are stitched in place and they’re kept in place for few weeks until the patient has a chance to see the ear, nose and throat specialist. At that first visit with the ear, nose and throat specialist, those sheets will be removed and the nose will be inspected for any scar tissue and generally the breathing gets much easier after those are removed.

The issues to look for once a patient goes home would be leakage of clear, watery fluid dripping out of the nose. It would look like faucet that’s dripping. If that were to occur, the person should collect some of that fluid in a clean container – like a bottle – and bring it to the hospital and notify the doctors right away. It will be tested for a chemical called Beta Two Transferin, which is a chemical that is only found in the cerebral spinal fluid or the brain water to determine if it’s actually a leakage from the brain or not. If there’s any gushes of bleeding or any worrisome bleeding, patient should come to the hospital. If there is excessive bad odor coming from the nose, person should come back. If the person is noticing any problems with their vision, where initially it got better and now it’s getting worse, they should certainly come to the hospital.

Worsening headaches or persisting headaches would be a sign to come to the hospital or notify the physician. And of course, any problem where there’s a general lack of energy, the person develops severe dizziness or vomiting – can’t keep any food down which might suggest a lack of a hormone, the person should come. Or that the person is excessively thirty and constantly drinking water, constantly passing their water, getting up at night, 3, 4, 5, 6 times a night to pass their water and constantly needing to drink. These are a signs of a lack of hormones that are going on and can easily be treated by replacing those hormones that are responsible for that.

Speaker: Dr. Michael Cusimano

Video transcript

The team at St. Mike’s has lots of experience doing pituitary surgery. It’s a routine operation for us. We do approximately 40 to 60 of these operations per year and we’ll see several hundred of these patients every year. The number is constantly growing and so it’s a common procedure that we undertake.

The team generally consists of endocrinologists or hormone specialists who also correspondingly has lots of experience with ear, nose, and throat specialists or surgeon who specialize in the nasal cavity and sinuses around the nose. The neurosurgeon and often an optomologist, which may or may not be at St. Michael’s hospital or a neuro-optomologist. And so the whole team has lots of experience in dealing with patients with these types of problems.

We’ve done a lot of research in the area and we clearly do a lot of education, both locally with trainees from local universities in Ontario, but also have trained neurosurgeons and other specialists around the world who come to St. Michael’s to learn the technique and to perfect the technique and take it back to their own countries.

I: How long did you say this transsphenoidal technique has been around for? Is it you that developed this specific technique?

Well the original transsphenoidal operation was done in 1908 I believe, the very first one, but obviously that was using very crude methods and it wasn’t very safe. The first one if you can believe it was not even done under a general anesthetic. Now, the methods were improved with general anesthesia but the ways of visualizing things didn’t improve really until the 1960’s when the microscope was used to do this. And so, the surgeons in the 1960’s in Montreal actually started doing the procedure with the microscope through the nose, but they often used the upper lip to get to the nose to get more room so that there was enough light to see in.

The innovation that we did was that we decided to use telescopes or what are called endoscopes in the early 1990’s. We did our first operation in the 1993 using this and we first published a few years later in 1996 about the technique. We will use both nostrils, one for the telescope or endoscope and the other one for the instruments that we use. We’ll often use instruments on both sides. We accomplish this by making a small opening at the very back of the nasal septum so that we can see and work from both sides of the nose.

This in fact was very simple idea but something that hadn’t been done before we described it in any length or detail. Since we described it people from all over the world have been incorporating it and now it’s kind of a routine operation around the world.

Speaker: Dr. Jeannette Goguen, endocrinologist

Video transcript

Hi my name is Dr. Goguen. I’m one of the endocrinologists here at St. Michael’s Hospital at the University of Toronto. An endocrinologist, or hormone doctor, is one of the doctors you’ll be seeing to manage your pituitary disease. A lot of people don’t explain the role of the endocrinologist and I’m here to explain it.

Let’s start with the pituitary gland. The pituitary gland is a very exciting gland for the endocrinologist because it’s also called the master gland because it makes so many hormones that circulate through the body that affect so many other glands that make additional hormones; it becomes a very complex situation.

The pituitary itself makes seven hormones; the most important is ACTH that stimulates the adrenal glands which sit on top of the kidneys. The adrenal glands produce cortisol and you need cortisol to live; without it, people become very sick, they get nausea, vomiting, dizziness weight loss, their blood pressure drops, and in extreme cases you can die from deficiency. The pituitary also makes TSH, which is the hormone that drives the thyroid gland in the neck which is used to produce T4 and T3. If these are deficient the person has an alteration in the level of their basal metabolic rate and they can get quite sick from that too.

The pituitary makes LH and FSH which circulate and affect sexual function – ovaries in the women and the testicles in men. The pituitary makes prolactin which affects milk production in women who’s breast feeding. The pituitary makes GH which allow children to grow into adult heights; deficiency in this can cause symptoms in the adult as well.

And finally it makes ADH which allows the kidneys to conserve water. Without this you can urinate up to 6 litres a day and becomes very difficult to keep up drinking water.

Speaker: Dr. Jeannette Goguen, endocrinologist

Video transcript

So when would you typically see an endocrinologists if you have a pituitary tumour? Well you should see me before surgery, at the time of surgery, and even after the surgery as well.

You need to see a pituitary doctor, endocrinologist, before surgery for several reasons. One, to assess if you have the over-function of the pituitary we were discussing. If you have a prolocatinoma, that is treated over 90 per cent of the cases just with medication so that could save you having to go through surgery. If you have Cushing’s or acromegaly, you will almost certainly need surgery. There are some medications that can help before surgery as well. If you have deficiencies of pituitary hormones, some of those will need to be replaced in order to have safe surgery. Some of them may recover after surgery which is the potential good news. As well some of the medical problems, like Cushing’s or arcomegaly, can have associated additional problems like diabetes, hypertension, or heart disease and I can help you diagnose if any of those are present and help manage those as well before surgery. During surgery you’ll be with the neurosurgeon, but after that the endocrinologist will follow you in hospital to look for any acute loss of the most important pituitary hormone. Those are ACTH, which is monitored by cortisol levels. If the cortisol falls too low, I’ve already indicated that’s the most important hormone, we will replace that in the hospital. That’s monitored closely well in hospital.

The second thing you will learn after surgery is sometimes ADH, or water conserving hormone, can be disrupted by surgery that can be temporary or permanent. It can lead to large volume of urine output, you’l find yourself very thirsty drinking water. And if you can’t keep up that can cause your blood sodium level to fluctuate and that can be quite serious so we also monitor very closely for that. We can replace ADH as DDAVP if we need to.

Finally, you’re discharged after few days and you’ll go home. You’ll see an endocrinologist typically between 3 to 6 weeks after discharge. And my job then is to see if you’re on the DDAVP, do you still need it. If you’re taking any steroid replacement, cortisol replacement for ACTH deficiency, do you still need it. Or have new hormonal deficiencies manifested themselves and need to be treated at that point. As well, if you’ve had overproduction of any of the prolactin hormone, the ACTH causing Cushing’s, the growth hormone causing acromegaly, we’ll check after surgery to see if you’re cured or not. If you’re not cured, you may need a second surgery or you may need medications to treat that.

So after discharge home from the hospital, after your pituitary surgery. you’ll be asked to do some blood test within a week or two of discharge. You’ll see the endocrinologist shortly after that as well as the ENT, the ear nose throat doctor, to get the tubes out of your nose. You’ll have an MRI booked in a month or two after surgery and you’ll see the neurosurgeon. You should also make an appointment to see your eye specialist as well. If all is well, and there’s no hormonal manipulations, you’ll typically see the endocrinologist 4 to 6 months after that and then every 6 to 12 months on ongoing basis to monitor for excess hormonal deficiencies and to monitor your MRI.

Video transcript

I’m Dr. John Lee, I’m one of the otolaryngologists (ear nose and throat surgeons) here at St. Michael’s Hospital and I’m one of the members in the pituitary program and team. Myself and also our chief in the Ear Nose and Throat department, Dr. Jennifer Anderson, are the members in the pituitary program.

So if you take a look at the skull, the pituitary gland sits right here, at the base. In the old days, you would have to approach this using more invasive approaches, sometimes through cuts on the face, sometimes through a craniotomy, sometimes through cuts underneath the lip and upper gum. But over the last 15-20 years, we’ve understood that we can actually be more minimally invasive and use the nose and use the sinuses to access this area. To understand that, you can split the skull in half and sort of see that if the pituitary gland is sitting in this region here, and we can actually use the nose and sinuses as a corridor to access this base of the skull. There are no cuts to the face and it allows us to get excellent visualization of this area in the base of the skull. We use instruments such as these called the endoscope which allows us to visualize and see these areas. And so the otolaryngologist really helps access this area, helps provide visualization and approach to access the tumour, and together with the neurosurgeon, and then proceed to open up the base of the skull, access the pituitary tumour and then remove it following the surgery.

So if you think of the ear nose and throat surgeon, either myself or Dr. Jennifer Anderson as navigating the boat to the dock. And so we will navigate the boat through the nose, and then through the sinuses, to the dock, and then Dr. Cusimano is there to unload the passengers and together, we can remove the ship out from there through the nose and sinuses.

Cristina Lucarini – secretary to Dr. Cusimano

Video transcript

I see the pituitary patients after the referral comes in, which gets forwarded to Dr. Cusimano – that’s their first venture into neurosurgery. He reviews the information and prioritizes everything for me and there is a whole gamut of tests that need to be set up for them. I book most of the tests myself, but for some of them, we ask the referring doctor to help us out. Then patients come in to see Dr. Cusimano and they usually get booked for surgery. A lot of them do end up going to surgery and in between that process, there are pre-admission appointments that need to get done, sometimes MRI scans that need to be booked, CT scans, and visual field tests. If those haven’t been done before, they get done before the surgery, and then the patient goes to the OR.

After that, there’s a recovery process and they have a lot of questions, because sometimes things don’t always work out the way they expect or things happen that they’re not sure of, so they call me. If I can answer their questions, great, but if not, I will refer them to Dr. Cusimano or other nurse practitioners. Sometimes it’s very emotional and you can be on the phone with them for quite a long period of time, just because they’re nervous, they’ve never had this done before, and they have a lot of different questions such as how it’s going to affect them. You just try to talk them through it. I’ve never had this surgery before but you hear a lot from other patients who have, so there are certain things you can answer right away and reassure them that Dr. Cusimano is excellent at it and it’s a relatively “simple” procedure compared to some of the other things that he does. But when it’s the first time for you, it’s a big deal and they get really nervous so it’s just nice to be able to talk them through it.

I’m a little bit more casual with the patients than I think I should be sometimes; I try to use first names as often as I can, so I would say something like, “Julian, this is what you’re going to be going through. We’re going to be booking the follow-up appointments for you, the pre-admission appointments for you, you’re going to be coming in for surgery the same day, you’ll be checking in between 6 and 6:30, depending on the time of your surgery…etc.” So it’s very one-to-one. I try not to use “Mr. and Mrs.”, unless I feel that they would prefer that, and that’s fine, too, but I’m usually on a first-name basis with the patients – I like it better and I think they prefer it too, because we’re all at the same level, going through it together.