Intranasal presentations of pituitary tumours are rare. Management can be difficult and delayed due to their location and extension. Macroprolactinomas are uncommon and can often pursue an aggressive clinical course, including invasion into the nasopharynx.
We describe three cases of prolactinomas that initially presented to the ENT Department as nasal polyps. Table 1 highlights their clinical features and response to treatment. Recurrence of nasal polyps (patient 1) and radiological evidence of a pituitary mass (patient 2 and 3) prompted testing for a prolactinoma. None of the patients had any signs of hyperprolactinaemia. All have significant residual tumour at follow up, despite prolactin levels approaching the normal range on dopaminergic therapy.
|Patient||Age (years)||Presentation||Cabergoline maintenance dose (mg)||% Reduction in tumour size at follow up||Follow up (years)||Serum prolactin (mU/L) baseline/follow up|
|1||44||Nasal obstruction, epistaxis||2 mg daily||1520%||4||384 000|
|2||33||Nasal blockage, headache||5 mg/week||26%||2||267 000|
|3||63||Left Horners, epistaxis, headache||0.25 mg daily||50%||1||14 000|
Pituitary tumours that invade the nasal cavity are rare and clinicians should be aware of their existence. Measurement of serum prolactin and immuno-histochemistry for prolactin secreting cells in intranasal tumours should be considered if there is clinical evidence of hyperprolactinaemia or if there is recurrence of the nasal tumour/polyp. This can expedite a diagnosis and prevent delay of treatment with dopamine agonists. Dopaminergic therapy controls excessive prolactin secretion and results in tumour shrinkage in most patients, but treatment may be complicated by dopamine resistance, extensive tumour necrosis and CSF rhinorrhoea.