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Hasegawa H, Kondo K, Ishihara S, Shinya Y, Kiyofuji S, Umekawa M, Saito N. Endoscopic endonasal drainage of a middle fossa epidural abscess in conjunction with endoscopic sinus surgery: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2024; 8:CASE24288. [PMID: 39133942 PMCID: PMC11323852 DOI: 10.3171/case24288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/07/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Recent anatomical studies have reported the feasibility of the endoscopic endonasal approach to the middle fossa. However, its clinical applicability has been discussed in only a few cases. This article describes the case of a middle fossa epidural abscess successfully drained through a fully endoscopic endonasal corridor and discusses the key technical points. OBSERVATIONS The authors describe an 8-year-old boy who presented with worsening headache, fatigue, emesis, and fever and was diagnosed with a left middle fossa epidural abscess associated with sphenoid sinusitis. Following endoscopic sinus surgery performed by a rhinologist, the middle fossa was accessed by removing the maxillary strut through the transmaxillary transpterygoid corridor. Complete drainage of the abscess was confirmed on postoperative magnetic resonance imaging. The patient tolerated the surgery without neurological deficit and demonstrated prompt symptom improvement. He was discharged home after completing a 6-week course of antibiotic therapy and remained free from recurrence at 1 year following surgery. LESSONS The endoscopic endonasal approach may be applicable to a middle fossa epidural abscess, resulting in prompt clinical improvement. The maxillary strut is a key structure for entering the middle fossa. https://thejns.org/doi/10.3171/CASE24288.
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Affiliation(s)
- Hirotaka Hasegawa
- Departments of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Kenji Kondo
- Departments of Otorhinolaryngology, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Sayaka Ishihara
- Departments of Pediatrics, The University of Tokyo, Bunkyo, Tokyo, Japan
- Department of Pediatrics, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Yuki Shinya
- Departments of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Satoshi Kiyofuji
- Departments of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Motoyuki Umekawa
- Departments of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Nobuhito Saito
- Departments of Neurosurgery, The University of Tokyo, Bunkyo, Tokyo, Japan
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2
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Rosas Herrera A, Parker AB, Chaskes M, Askin F, Monk AS, Stephens JR, Thorp BD, Ebert CS, Senior BA, Kimple AJ, Kong KA. Unilateral Periorbital Swelling in a Pediatric Patient. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2024; 17:11795476241255563. [PMID: 38827640 PMCID: PMC11143867 DOI: 10.1177/11795476241255563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 04/26/2024] [Indexed: 06/04/2024]
Abstract
Infratemporal fossa (ITF) tumors are rare in children and may present with a variety of symptoms. Teratomas are neoplasms derived from the 3 germ layers and approximately 6% to 10% are within the head and neck. Our study discusses one of the first reported cases of teratoma in the ITF in a pediatric patient. A 3-year-old girl presents with 2 years of recurrent monthly left periorbital swelling accompanied by fevers, skin discoloration, and pain. Prior episodes were treated with antibiotics with incomplete resolution. Imaging revealed a cystic lesion centered in the ITF. She was taken for endoscopic endonasal biopsy of the lesion and had no complications. Pathology revealed a mature teratoma composed primarily of pancreatic tissue. Providers should consider masses such as teratoma in the differential for ITF tumors and periorbital edema unresponsive to typical treatment.
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Affiliation(s)
- Ana Rosas Herrera
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ashley B Parker
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Mark Chaskes
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Frederic Askin
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Aurelia S Monk
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John R Stephens
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Brian D Thorp
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles S Ebert
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brent A Senior
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam J Kimple
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keonho A Kong
- Department of Otolaryngology—Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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3
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Valencia-Sanchez BA, Kim JD, Zhou S, Chen S, Levy ML, Roxbury C, Patel VA, Polster SP. Special Considerations in Pediatric Endoscopic Skull Base Surgery. J Clin Med 2024; 13:1924. [PMID: 38610689 PMCID: PMC11013018 DOI: 10.3390/jcm13071924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.
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Affiliation(s)
| | - Jeeho D. Kim
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Sheng Zhou
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Los Angeles, CA 90033, USA
| | - Sonja Chen
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
| | - Michael L. Levy
- Division of Pediatric Neurosurgery, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Neurosurgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology, University of Chicago Medicine, Chicago, IL 60637, USA;
| | - Vijay A. Patel
- Division of Pediatric Otolaryngology, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Sean P. Polster
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
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4
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Raskin J, Borrelli M, Wrobel B. An Endoscopic Endonasal Attempt at Pediatric Meningoencephalocele Repair. EAR, NOSE & THROAT JOURNAL 2023; 102:24S-26S. [PMID: 37574852 DOI: 10.1177/01455613231187760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
Meningoencephalocele is an abnormal skull base protrusion of fluid, brain tissue, and meninges that can lead to nasal obstruction, meningitis, and Cerebrospinal Fluid (CSF) rhinorrhea. This condition can be managed operatively through an open craniotomy or a less invasive endoscopic approach. Here, we report a case of an 18-month-old female who presented with a meningoencephalocele that was part of the Sakoda complex, a rare neurosurgical phenomenon consisting of meningoencephalocele, agenesis of the corpus callosum, and cleft lip/palate. The patient was initially treated with the endoscopic transsphenoidal approach with subsequent open craniotomy.
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Affiliation(s)
- Jonathan Raskin
- Oakland University William Beaumont School of Medicine, Detroit, MI, USA
- Cedars Sinai Sinus Center of Excellence, Los Angeles, CA, USA
| | - Michela Borrelli
- Cedars Sinai Sinus Center of Excellence, Los Angeles, CA, USA
- Cedars Sinai Division of Otolaryngology, Los Angeles, CA, USA
| | - Bozena Wrobel
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA
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Battistin U, Maiti T, Elhammady MS, Roser F. Two-Stage Resection of a Giant Trigeminal Schwannoma in a Non-Neurofibromatosis Type 2 Pediatric Patient: A Case Report, Systematic Review, and Intraoperative Video. World Neurosurg 2023; 171:e323-e335. [PMID: 36521756 DOI: 10.1016/j.wneu.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Trigeminal schwannoma is an uncommon tumor in pediatric patients. Several surgical approaches have been described in the literature. METHODS The case of an 11-year-old boy with a giant dumbbell-shaped trigeminal schwannoma removed through a 2-stage approach was presented with an intraoperative video. Using PubMed and Scopus, the literature on trigeminal schwannoma in pediatric patients was searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS The search strategy yielded 312 titles, of which 13 were included in the review. Cases of trigeminal schwannoma were described, with a highly variable clinical presentation and anatomical arrangement in cranial fossae. Two-stage approaches were reported, although most studies described single-stage approaches. Common postoperative outcomes were a range of disturbances of cranial nerve V. CONCLUSIONS The surgical approach varies based on the tumor conformation. However, a 2-stage pterional subtemporal and semisitting retrosigmoid approach is a safe, practical, and effective strategy for the removal of dumbbell-shaped trigeminal schwannoma in a pediatric patient.
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Affiliation(s)
- Umberto Battistin
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Tanmoy Maiti
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Mohammed S Elhammady
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Florian Roser
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
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Carle TR, Wung V, Heaney AP, Chiu HK, Suh JD, Bergsneider M, Wang MB. Sinonasal Symptom Outcomes following Endoscopic Anterior Cranial Base Surgery in the Pediatric Population. Skull Base Surg 2022; 83:e312-e317. [DOI: 10.1055/s-0041-1729976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/24/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective This study aimed to evaluate the impact of endoscopic anterior cranial base (ACB) surgery on sinonasal symptoms in the pediatric population utilizing the Sino-Nasal Outcome Test (SNOT)-22 questionnaire.
Design This is a retrospective review.
Setting The study was conducted at a tertiary academic medical center.
Participants Thirty-four consecutive patients, age 6 to 17 years, M:F 14:20, who underwent endoscopic ACB surgery from July 2008 to August 2019. Ten patients had baseline and a minimum of two subsequent postoperative SNOT-22 questionnaires available for analysis.
Main Outcome Measures Baseline and postoperative SNOT-22 scores were compared. The mean change from baseline sinonasal symptom scores in the pediatric and historical adult cohorts was compared.
Results The mean baseline SNOT-22 score for our 10 patient cohort was 0.46 out of 5 for each of the first 10 sinonasal-specific questions. This worsened to 1.69 at 1 month and returned to near baseline, 0.7, at 3 months postoperatively. The mean quality-of-life score improved to 0.91 at 1 month and 0.6 at 3 months postoperatively. The mean change from baseline for the following items: need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable were similar to those in our historical adult cohort at 3 months postoperatively.
Conclusion Endoscopic ACB surgery in the pediatric population results in increased sinonasal symptom morbidity in the early postoperative period; however, symptoms return to near baseline by ∼3 months, and quality-of-life scores progressively improve in the postoperative period. These trends were similar to those seen in our historic adult cohort.
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Affiliation(s)
- Taylor R. Carle
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, United States
| | - Vivian Wung
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, United States
| | - Anthony P. Heaney
- Department of Medicine, Endocrinology—Diabetes and Metabolism, University of California, Los Angeles, Los Angeles, California, United States
| | - Harvey K. Chiu
- Department of Pediatrics, Endocrinology, University of California, Los Angeles, Los Angeles, California, United States
| | - Jeffrey D. Suh
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, United States
| | - Marvin Bergsneider
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, United States
| | - Marilene B. Wang
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, United States
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7
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Singh R, Thorwarth RM, Bendok BR, Rath TJ, Bhuskute AA, Gnagi SH, Lal D. Association of meningitis and clival canal defect: case illustration, management, and systematic review of the literature. J Neurosurg Pediatr 2022; 29:379-386. [PMID: 35171832 DOI: 10.3171/2021.11.peds21388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Improper embryological development of the clivus, a bony structure that comprises part of the skull base, can lead to a clival canal defect. Previously thought to be a benign condition, clival canals have been reported to be associated with meningitis and meningoceles. In this review, the authors sought to present an unpublished case of a patient with a clival canal defect associated with meningitis and to evaluate all other reported cases. METHODS In October 2020, a search of PubMed, Web of Science, and Scopus was conducted to identify all cases of clival canals reported from January 1, 1980, through October 31, 2020. RESULTS Including the case presented herein, 13 cases of clival canals, 11 in children (84.6%) and 2 in adults (15.4%), have been identified. Of the pediatric patients, 5 (45.5%) had an associated meningocele, and 8 (72.7%) had meningitis. Nine of the 13 patients (69.2%) had defects that were treated surgically, 5 (38.5%) by a transnasal approach and 4 (30.8%) by a transoral approach. Two patients (15.4%) were treated with drainage and antibiotics, 1 patient (7.7%) was treated solely with antibiotics, and 1 patient (7.7%) was not treated. In the literature review, 8 reports of clival canals were found to be associated with meningitis, further contributing to the notion that the clival canal may be an overlooked source of recurrent infection. In several of these cases, surgical repair of the lesion was curative, thus preventing continued episodes of meningitis. CONCLUSIONS When a patient has recurrent meningitis with no clear cause, taking a closer look at clival anatomy is recommended. In addition, if a clival canal defect has been identified, surgical repair should be considered a safe and effective primary treatment option.
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Affiliation(s)
- Rohin Singh
- 1Mayo Clinic Alix School of Medicine, Scottsdale
| | - Ryan M Thorwarth
- 2Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Phoenix
| | - Bernard R Bendok
- 3Department of Otolaryngology, Mayo Clinic Hospital, Phoenix.,5Department of Neurologic Surgery, Mayo Clinic Hospital, Phoenix; and
| | - Tanya J Rath
- 4Department of Radiology, Mayo Clinic Hospital, Phoenix
| | - Aditi A Bhuskute
- 6Department of Otolaryngology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Sharon H Gnagi
- 6Department of Otolaryngology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Devyani Lal
- 3Department of Otolaryngology, Mayo Clinic Hospital, Phoenix
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8
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Lopez EM, Farzal Z, Dean KM, Miller C, Morse JC, Ebert CS, Kimple AJ, Thorp BD, Zanation AM. Outcomes in Pediatric Endoscopic Skull Base Surgery: A Systematic Review. Skull Base Surg 2022; 84:24-37. [PMID: 36743708 PMCID: PMC9897900 DOI: 10.1055/a-1725-9151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 12/14/2021] [Indexed: 02/07/2023]
Abstract
Objectives The frequency of endoscopic skull base surgery in pediatric patients is increasing. This study aims to systematically review the literature for endoscopic skull base surgery outcomes in children/adolescents aged 0 to 18 years. Design A systematic review of the literature was performed in PubMed and SCOPUS databases querying studies from 2000 to 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Final inclusion criteria included: case series with more than 10 patients with pediatric patients aged ≤18 years, endoscopic or endoscopic-assisted skull base surgery, and outcomes reported. Setting This study was conducted at a tertiary care medical center. Participants Children/adolescents aged 0 to 18 years who underwent endoscopic skull base surgery were participated in this study. Main Outcome Measures Patient demographics, pathology, reconstructive technique, intraoperative findings, intraoperative, and postoperative surgical complications were measured through this study. Results Systematic literature search yielded 287 publications. Of these, 12 studies discussing a total of 399 patients aged 0 to 18 years met inclusion criteria for final analysis. Seven of the 12 studies discussed a single pathology. The most common pathology was a skull base defect causing cerebrospinal fluid (CSF) leak. The majority of skull base repairs were made with free tissue grafts. The most common postoperative complication was CSF leak ( n = 40). Twelve cases of meningitis occurred postoperatively with two of these episodes resulting in death. Conclusion Endoscopic skull base surgery has been performed recently in the pediatric population in a variety of disease states. Inconsistent individual-level data and reporting standards are present in existing studies posing challenges for comparative analysis. Standardized reporting will aid future reviews and meta-analysis for rare skull base pathology.
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Affiliation(s)
- Erin M. Lopez
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States,Address for correspondence Erin M. Lopez, MD Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals170 Manning Dr. CB 7070, Physician Office Building Room G190A, Chapel Hill, NC 27599United States
| | - Zainab Farzal
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
| | - Kelly M. Dean
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
| | - Craig Miller
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
| | - Justin C. Morse
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
| | - Charles S. Ebert
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
| | - Adam J. Kimple
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
| | - Brian D. Thorp
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
| | - Adam M. Zanation
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina Memorial Hospitals, Chapel Hill, North Carolina, United States
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9
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Imaging of Developmental Skull Base Abnormalities. Neuroimaging Clin N Am 2021; 31:621-647. [PMID: 34689936 DOI: 10.1016/j.nic.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The skull base is a critical structure in the craniofacial region, supporting the brain and vital facial structures in addition to serving as a passageway for important structures entering and exiting the cranial cavity. This paper will review and highlight some of the embryology, developmental anatomy, including ossification, and related abnormalities of the anterior, central and posterior skull base using illustrative cases and tables. Pathologies such as dermoids/epidermoids, cephaloceles, nasal gliomas, glioneuronal heterotopias, various notochordal remnants, persistent craniopharyngeal canal, teratomas, platybasia, basilar invagination, clival anomalies and Chiari malformations will be discussed. Developmental pearls and pitfalls will also be highlighted.
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10
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Ballestero MFM, de Souza SNF, Pacheco Neto RC, Gondim GGP, Valera ET, Dos Reis MBF, Colli BO, de Oliveira RS. Pediatric Skull Base Tumors: A Management Challenge. J Pediatr Neurosci 2021; 16:35-43. [PMID: 34316306 PMCID: PMC8276951 DOI: 10.4103/jpn.jpn_56_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/29/2020] [Accepted: 08/17/2020] [Indexed: 12/29/2022] Open
Abstract
Context Skull base tumors are varied in children and are particularly challenging to pediatric neurosurgeons, with few papers in the literature describing the evolution, complications, and outcome. The authors evaluated long-term outcomes in children submitted to skull base tumor surgery and performed a literature review. Aims The aim of this study was to analyze surgical results, complications, and outcomes, on comparison with previous publications. Materials and Methods A retrospective analysis of children undergoing surgery at a single institution between 2000 and 2018 for lesions of the cranial base was carried out. In addition, a literature review was carried out describing a total of 115 children operated on for skull base tumors. Statistical Analysis Chi-squared and Fisher's exact tests were performed to compare the distribution of categorical variables and a nonparametric Mann-Whitney U test was used to perform intergroup comparisons of continuous variables. Results Seventeen children ranging in age from 8 months to 17 years (mean, 10.9 years) underwent skull base approaches. Tumor types included schwannoma, meningioma, chondroid chordoma, mature teratoma, epidermoid cyst, hemangiopericytoma, rhabdomyosarcoma, myofibroblastic inflammatory tumor, fibromyxoid sarcoma, Crooke's cell adenoma, ossifying fibroma, osteoblastoma, nasopharyngeal angiofibroma and Ewing's sarcoma. Gross total resection was achieved in 6 patients (35.3%), 12 patients (70.6%) had benign histology, and 5 patients (29.4%) had a malignant tumor. Transient postoperative cerebrospinal fluid leak affected only one patient. Thirteen children (76.4%) had a residual neurological deficit at last follow-up evaluation. Three (17.6%) surviving patients received adjuvant therapy. The rate of recurrence or lesion progression was 17.6%. Conclusions Skull base tumors in children present a therapeutic challenge because of their unique pathological composition and can lead to considerable morbidity and mortality in pediatric age.
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Affiliation(s)
- Matheus F M Ballestero
- Department of Medicine, Federal University of São Carlos, São Carlos, Brazil.,Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Stephanie N F de Souza
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Romilto C Pacheco Neto
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Guilherme G P Gondim
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Elvis T Valera
- Division of Pediatric Neuroncology, Department of Pediatrics, Ribeirão Preto Medical School, University of Sao Paulo, São Carlos, Brazil
| | - Maristella B F Dos Reis
- Division of Pediatric Neuroncology, Department of Pediatrics, Ribeirão Preto Medical School, University of Sao Paulo, São Carlos, Brazil
| | - Benedicto O Colli
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ricardo S de Oliveira
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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11
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Landry AP, Ye VC, Vaughan KA, Drake JM, Dirks PB, Cusimano MD. Pediatric multicompartmental trigeminal schwannoma: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2171. [PMID: 35855022 PMCID: PMC9245852 DOI: 10.3171/case2171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/28/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Trigeminal schwannoma (TS) is an uncommon and histologically benign intracranial lesion that can involve any segment of the fifth cranial nerve. Given its often impressive size at diagnosis and frequent involvement of critical neurovascular structures of the skull base, it represents a challenging entity to treat. Pediatric TS is particularly rare and presents unique challenges. Similarly, tumors with extension into multiple compartments (e.g., middle cranial fossa, posterior cranial fossa, extracranial spaces) are notoriously difficult to treat surgically. Combined or staged surgical approaches are typically required to address them, with radiosurgical treatment as an adjunct. OBSERVATIONS The authors presented the unusual case of a 9-year-old boy with a large, recurrent multicompartmental TS involving Meckel’s cave, the cerebellopontine angle, and the infratemporal fossa. Near-total resection was achieved using a frontotemporal-orbitozygomatic craniotomy with a combined interdural and extradural approach. LESSONS The case report adds to the current literature on multicompartmental TSs in children and their management. The authors also provided a simplified classification of TS that can be generalized to other skull base tumors. Given a lack of precedent, the authors intended to add to the discussion regarding surgical management of these rare and challenging skull base lesions.
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Affiliation(s)
| | - Vincent C. Ye
- Divison of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Kerry A. Vaughan
- Divison of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; and
| | - James M. Drake
- Divison of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; and
| | - Peter B. Dirks
- Divison of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; and
| | - Michael D. Cusimano
- Divison of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; and
- Division of Neurosurgery, St. Michael’s Hospital, Toronto, Ontario, Canada
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12
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Wu T, Chandy Z, Ference E, Lee JT. Endoscopic Skull Base Surgery in the Pediatric Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00288-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Background
Surgery is often indicated for definitive biopsy or as the primary treatment modality for pediatric skull base lesions. Traditionally, open surgical approaches were utilized to address pediatric skull base pathology. However recently, expanded endoscopic sinus surgery has been utilized as a minimally invasive approach to addressing skull base pathology in the pediatric population.
Purpose
This review provides an overview of the current literature evaluating the unique anatomic challenges of the pediatric skull and the safety and efficacy of expanded skull base procedures in the pediatric population.
Findings
The pediatric skull base and sinus anatomy is small and continues to develop throughout childhood leading to unique surgical challenges. Sphenoid sinus pneumatization and intercarotid distance at the skull base are two significant anatomic challenges to pediatric skull base surgery. Despite the distinctive anatomy challenges, recent studies demonstrate that the safety and efficacy of expanded endoscopic sinus surgery appear to be equivalent to traditional open surgical approaches.
Conclusion
Expanded endoscopic sinus surgery in the pediatric population has similar efficacy and safety as the traditional open approaches.
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London NR, Rangel GG, VanKoevering K, Zhang A, Powell AR, Prevedello DM, Carrau RL, Walz PC. Simulation of Pediatric Anterior Skull Base Anatomy Using a 3D Printed Model. World Neurosurg 2021; 147:e405-e410. [PMID: 33359526 DOI: 10.1016/j.wneu.2020.12.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The pediatric skull base may present anatomic challenges to the skull base surgeon, including limited sphenoid pneumatization and a narrow nasal corridor. The rare nature of pediatric skull base pathology makes it difficult to gain experience with these anatomic challenges. The objective of this study was to create a 3-dimensionally (3D) printed model of the pediatric skull base and assess its potential as a training tool. METHODS Twenty-eight participants at various stages of training and practice were included in our study. They completed a pre- and postdissection questionnaire assessing challenges with endoscopic endonasal skeletonization of the carotid arteries and sella face using the 3D printed model. RESULTS The majority of participants had completed a skull base surgery fellowship (60.7%), were <5 years into practice (60.7%), and had <10 cases of pediatric skull base experience (82.1%). Anticipated challenges included limitation of maneuverability of instruments (71.4%), narrow nasal corridor and nonpneumatized bone (57.1%). On a scale of 0-10, 10 being very difficult, the average participant expected level of difficulty with visualization was 6.89 and expected level of difficulty with instrumentation was 7.3. On postdissection assessment, there was a nonstatistically significant change to 6.93 and 7.5, respectively. Participants endorsed on a scale of 0-10, 10 being very realistic, an overall model realism of 7.0 and haptic realism of 7.1. CONCLUSIONS A 3D printed model of the pediatric skull base may provide a realistic model to help participants gain experience with anatomic limitations characteristic of the pediatric anterior skull base.
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Affiliation(s)
- Nyall R London
- Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA; Otolaryngology Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Gustavo G Rangel
- Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kyle VanKoevering
- Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashley Zhang
- Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Allison R Powell
- Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel M Prevedello
- Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA; Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA; Neurological Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Patrick C Walz
- Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.
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Le Fort I Down-Fracture for Management of Midface Tumors. J Craniofac Surg 2020; 31:e608-e612. [PMID: 32649545 DOI: 10.1097/scs.0000000000006705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To perform an integrative review associating current literature with a clinical series regarding the use of Le Fort I osteotomy for the removal of tumors located in the midface and central region of the skull base. METHODS A systematic review was performed through the PubMed, SCOPUS, and Cochrane databases. In addition, 4 different patients operated using the above-cited technique are described in this study. RESULTS Initially, 123 articles were found. After the removal of duplicates, and title and abstract reading, 27 articles were selected for data extraction. The Le Fort I surgical approach of tumors was performed in 183 patients. CONCLUSION The Le Fort I surgical approach allows lesion exeresis with good visualization, low rates of recurrences and complications, and without aesthetic compromises for the patient.
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LoPresti MA, Nguyen J, Lam SK. Pinning in pediatric neurosurgery: the modified rubber stopper technique. J Neurosurg Pediatr 2020; 26:98-103. [PMID: 32276245 DOI: 10.3171/2020.1.peds19541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/31/2020] [Indexed: 11/06/2022]
Abstract
Head immobilization devices with skull pins are commonly used by neurosurgeons to stabilize the head for microsurgical techniques and to maintain accurate intraoperative neuronavigation. Pediatric patients, who may have open fontanelles, unfused sutures, and thin skulls, are vulnerable to complications during placement in pins. We review the various methods of pinning in pediatric neurosurgery and revisit the modified rubber stopper technique using a commonly available rubber stopper from a medication bottle over a standard adult pin of a Mayfield head clamp to prevent the pins from plunging through the thin pediatric skull.
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Affiliation(s)
- Melissa A LoPresti
- 1Department of Neurosurgery, Baylor College of Medicine, Houston
- 2Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Joshua Nguyen
- 3Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago; and
- 4Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Sandi K Lam
- 3Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago; and
- 4Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
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London NR, Rangel GG, Onwuka A, Carrau RL, Prevedello DM, Leonard JA, Walz PC. Reconstruction of pediatric skull base defects: A retrospective analysis emphasizing the very young. Int J Pediatr Otorhinolaryngol 2020; 133:109962. [PMID: 32109673 DOI: 10.1016/j.ijporl.2020.109962] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/14/2020] [Accepted: 02/15/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Pathology of the pediatric skull base is rare and ranges from congenital defects to malignancy and traumatic defects. Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic challenges for the skull base surgeon. The goal of this study was to retrospectively review our experience with reconstruction of pediatric skull base defects with particular emphasis on those ≤6 years of age. METHODS A retrospective chart review was conducted of patients ≤20 years of age who underwent endoscopic endonasal and combined endoscopic and open approaches to address cranial base pathology from 2007 to 2018. Patients were divided into two groups; those ≤6 years of age (group A) and those >6 years of age and ≤20 years of age (group B) and reconstructive techniques and outcomes were analyzed. RESULTS Intraoperative communication with the subarachnoid space (CSF leak) was created in 50% (3/6) of patients ≤ 6 years of age compared to 32.7% (16/49) in patients > 6 years and ≤20 years of age (P < 0.40) in management of their skull base disease. A vascularized flap was utilized for reconstruction in 66.7% (4/6) of patients ≤ 6 years of age and included a nasoseptal flap in 33.3% (2/6). A vascularized flap was utilized for reconstruction in 38.8% (19/49) of patients > 6 years and ≤20 years of age and most commonly included a nasoseptal flap (22.4%, 11/49). A lumbar drain was utilized in 50% (3/6) of patients ≤ 6 years of age compared to 18.4% (9/49) in patients > 6 and ≤20 years of age (P < 0.08). Post-operative CSF leaks were encountered in 16.7% (1/6) of patients ≤ 6 years of age compared to 10.2% (5/49) in patients > 6 and ≤20 years of age (P < 0.63). Behavioral issues were noted to potentially contribute to failed skull base reconstruction in patients <6 years of age. CONCLUSIONS Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic and behavioral challenges for the skull base surgeon as highlighted in this study.
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Affiliation(s)
- Nyall R London
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Otolaryngology Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA; Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, MD, USA
| | - Gustavo G Rangel
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Jeffrey A Leonard
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick C Walz
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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17
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Management of Pediatric Sinonasal and Skull Base Lesions. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-00216-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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La Corte E, de Laurentis C, Acerbi F, Broggi M, Pipolo C, Maccari A, Felisati G, Ferroli P. Peel-Away Catheter Introducer Sheath for Reducing Nasal Traumatic Injury During Pediatric Endoscopic Skull Base Surgery. World Neurosurg 2019; 129:24-27. [PMID: 31426253 DOI: 10.1016/j.wneu.2019.05.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Pediatric endoscopic endonasal surgery represents a still-growing discipline to approach complex skull base lesions and is characterized by unfavorable anatomical conditions. Children have very small nostrils and narrow rhinosinusal corridors, which could lead more easily to accidental injury to the nasal structures. We describe the use of a peel-away catheter introducer sheath as an innovative and minimally invasive technique to further reduce surgical trauma to the nasal mucosa and structures in pediatric rhinoneurosurgery. METHODS From January 2009 to December 2018, the peel-away sheath technique was used in 6 pediatric endoscopic procedures for biopsy and/or removal of skull base tumors. RESULTS The endoscopic technique with the use of the peel-away catheter allowed clear visualization of the surgical field during the whole course of the procedure and good surgical maneuverability. The use of the peel-away sheath did not prolong the surgical operation time and provided a good working channel. No intraoperative or postoperative major complications were observed. No nasal short-term complications were registered in all patients. CONCLUSIONS The use of a peel-away catheter introducer sheath technique represents a valid adjunct in the endoscopic pediatric skull base surgery repertoire. It can help in avoiding inadvertent surgical traumas to the sinonasal structures, especially by residents and junior surgeons. This could potentially reduce postoperative nasal morbidity.
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Affiliation(s)
- Emanuele La Corte
- PhD School in Molecular and Translational Medicine, Department of Health Sciences, University of Milan, Milan, Italy; Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Camilla de Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carlotta Pipolo
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Alberto Maccari
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Giovanni Felisati
- Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Kuan EC, Kaufman AC, Lerner D, Kohanski MA, Tong CCL, Tajudeen BA, Parasher AK, Lee JYK, Storm PB, Palmer JN, Adappa ND. Lack of Sphenoid Pneumatization Does Not Affect Endoscopic Endonasal Pediatric Skull Base Surgery Outcomes. Laryngoscope 2018; 129:832-836. [PMID: 30520033 DOI: 10.1002/lary.27600] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/06/2018] [Accepted: 09/12/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediatric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns. STUDY DESIGN Retrospective chart review. METHODS A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center. RESULTS A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total operative time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959). CONCLUSIONS Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase complications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 129:832-836, 2019.
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Affiliation(s)
- Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California
| | - Adam C Kaufman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lerner
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Kohanski
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles C L Tong
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bobby A Tajudeen
- Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Arjun K Parasher
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Phillip B Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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