Influence of Pediatric Endoscopic Endonasal Skull Base Resections on Midface and Skull Base Development

American Rhinologic Society Expert Practice Statement: Indications and Recommendations for Septoplasty in Children

The goal of this American Rhinologic Society Expert Practice Statement (EPS) is to provide recommendations and guidance through evidence-based consensus statements regarding pediatric septoplasty. This EPS was developed following the previously published methodology and approval process. The topics of interest included appropriate indications, safety and efficacy, timing, relevant quality of life instruments, and surgical techniques. Following a modified Delphi approach, six statements were developed, five of which reached consensus and one that did not. These statements and accompanying evidence are summarized along with an assessment of future needs.

Effect of endoscopic endonasal skull base approaches on olfactory function and facial development in children

INTRODUCTION

Endoscopic approaches for skull base pathologies are increasingly being performed, and the subsequent complications, especially in the long term, have also been partially clarified. However, there is no information on the effects of endoscopic endonasal skull base surgeries (EESBS) in children on odor and facial development in parallel with long-term development. We conducted this study to investigate postoperative olfactory function and facial development in pediatric patients who underwent skull base surgery using the endoscopic endonasal method.

METHODS

We evaluated the smell test, sinonasal symptoms, and facial development of pediatric patients who underwent endoscopic endonasal skull base surgery after long-term follow-up. Odor was evaluated using the "Sniffin' Sticks" test kit, which assessed the T (odor threshold), D (odor discrimination), and I (odor identification) parameters. Sinonasal symptoms were evaluated using the SNOT-22 (sinus-nose outcome test) questionnaire. SNA (sella-nasion-A point), SNB (sella-nasion-B point), and ANB (A point-nasion-B point) angles were calculated from maxillofacial tomography and magnetic resonance imaging) to evaluate facial development. Data were compared with those of the healthy control group.

RESULTS

We included 30 patients comprising 19 (63.3%) boys and 11 (36.7%) girls, with no age difference between case and control groups. The mean follow-up period was 7 years. Odor test data, cephalometric measurements, and SNOT-22 analysis results showed no statistically significant differences between the two groups.

CONCLUSION

To our knowledge, this is a comprehensive study with the longest follow-up period in terms of evaluation of facial development after EESBS in children to analyze odor using the Sniffin' Sticks test kit and the quality of life using SNOT-22. Olfactory function, facial development, and quality of life remained unaffected after long-term follow-up after EESBS  in children. Although this surgical approach is minimally invasive, we recommend considering the possibility of complications, and the procedure should be performed by an experienced surgical team with adequate equipment.

Positioning Transclival Tumor-Treating Fields for the Treatment of Diffuse Intrinsic Pontine Gliomas

Diffuse intrinsic pontine glioma (DIPG) carries an extremely poor prognosis, with 2-year survival rates of <10% despite the maximal radiation therapy. DIPG cells have previously been shown to be sensitive to low-intensity electric fields in vitro. Accordingly, we sought to determine if the endoscopic endonasal (EE) implantation of an electrode array in the clivus would be feasible for the application of tumor-treating fields (TTF) in DIPG. Anatomic constraints are the main limitation in pediatric EE approaches. In our Boston Children’s Hospital’s DIPG cohort, we measured the average intercarotid distance (1.68 ± 0.36 cm), clival width (1.62 ± 0.19 cm), and clival length from the base of the sella (1.43 ± 0.69 cm). Using a linear regression model, we found that only clival length and sphenoid pneumatization were significantly associated with age (R2 = 0.568, p = 0.005 *; R2 = 0.605, p = 0.0002 *). Critically, neither of these parameters represent limitations to the implantation of a device within the dimensions of those currently available. Our findings confirm that the anatomy present within this age group is amenable to the placement of a 2 × 1 cm electrode array in 94% of patients examined. Our work serves to demonstrate the feasibility of implantable transclival devices for the provision of TTFs as a novel adjunctive therapy for DIPG.

Effects of CT/MRI Image Fusion on Cerebrovascular Protection, Postoperative Complications, and Limb Functional Recovery in Patients with Anterior and Middle Skull Base Tumors: Based on a Retrospective Cohort Study

Objective. To explore the effect of CT/MRI image fusion on cerebrovascular protection, postoperative complications and limb function recovery in patients with anterior and middle skull base tumors. Methods. During January 2019 to December 2021, a retrospective study was conducted on 50 patients who underwent anterior and middle skull base tumor resection in the same surgeon group in our hospital. According to the different surgical approaches, the patients were assigned to the fusion group (n = 29) and the routine group (n = 21). The routine group was operated with traditional operation, and the fusion group was operated with CT/MRI image fusion technique. The operation time, wound volume, resection rate and Karnofsky performance status (KPS), blood transfusion (vascular protection), tumor resection rate, and postoperative complications were compared. Results. The time of operation in the fusion group was shorter compared to the routine group, and the volume of the wound cavity in the fusion group was smaller compared to the routine group, and the difference was statistically significant ( $P<0.05$ ). Following treatment, the KPS score of the fusion group was remarkably higher compared to the routine group, and the difference was statistically significant ( $P<0.05$ ). The intraoperative blood transfusion rate in the fusion group was 17.24%, and the intraoperative blood transfusion rate in the routine group was 47.62%, and the difference was statistically significant ( $P<0.05$ ). The resection rate in the fusion group (89.66%) was remarkably higher compared to the routine group (61.90%, $P<0.05$ ). The incidence of postoperative complications in the fusion group (6.90%) was remarkably lower compared to the control group (33.33%, $P<0.05$ ). Conclusion. The application of CT/MRI image-fusion technology can effectively enhance the clinical symptoms of patients with tumors in the anterior and middle region of the skull base, which can promote the prognosis, shorten the operation time, reduce unnecessary cerebral neurovascular injuries, and retain more brain functions.

Complications of Endoscopic Skull Base Surgery for Sellar and Parasellar Tumors in Pediatric Population; Neurosurgical Perspectives

Background

Advances in surgical techniques based on in-depth anatomical knowledge of the skull base have broadened the indications for endoscopic skull base surgery (ESS) with the advantage of wide and direct surgical exposure while minimizing invasiveness. However, the low incidence of the indicated diseases and narrow surgical corridors in children have limited the popularization of ESS. In addition, surgical complications and preventive interventions are not yet well known. Therefore, we retrospectively investigated the complications and prevention methods of ESS in children with a comprehensive review.

Methods

We retrospectively analyzed the medical records of pediatric patients who underwent ESS for sellar and parasellar tumors at Seoul National University Children's Hospital from July 2010 to December 2020. Visual and endocrine status, extent of resection, complications, and recurrences were investigated depending on the pathology of the tumor. In addition, a comprehensive literature review regarding the complications of pediatric ESS was performed.

Results

A total of 98 patients were enrolled. The median age of the patients was 12 years, and 52 patients were male. Preoperative visual disturbance was found in 53 patients, anterior pituitary function deficit in 69, and diabetes insipidus in 32. Gross total resection was attempted in 67 patients and achieved in 62 (93%). Biopsy and cyst fenestration were the goals of surgery in 26 patients, and all were achieved as planned. Regarding outcomes, visual disturbance worsened in two patients (2%), endocrine status was aggravated in 34 (35%) patients, and new-onset diabetes insipidus occurred in 27 (41%) patients. The overall surgical complication rate (other than aggravation of visual or endocrine status) was 17%. Postoperative meningitis (12%) was the most common complication, followed by cerebrospinal fluid leakage (2%), vasospasm, hemorrhage and infarction. By pathological diagnosis, craniopharyngioma had the highest complication rate of 29%. All but one patient with postoperative hemorrhage showed no permanent deficits.

Conclusion

ESS in children is feasible and relatively safe. More attention and different postoperative management protocols are required in children to avoid complications, especially in craniopharyngiomas. However, the complications can be mostly managed conservatively without permanent neurologic deficits.

Maturation of the sella turcica and parasellar region: Surgical relevance for anterior skull base approaches in pediatric patients

OBJECTIVE

Traditional and extended transnasal transsphenoidal approaches provide direct access to a variety of anterior skull base pathologies. Despite increased utilization of transnasal approaches in children, anatomic studies on pediatric skull base maturation are limited. We herein perform a surgically relevant morphometric analysis of the sella and parasellar regions during pediatric maturation.

METHODS

Measurements of sellar length (SL), sellar depth (SDp), sellar diameter (SDm), interclinoid distance (ID), intercavernous distance (ICD), and the presence of sphenoid sinus pneumatization (SSP), and sphenoid sinus type (SST) were made on thin-cut CT scans from 60 patients (evenly grouped by ages 0-3, 4-7, 8-11 12-15, 16-18, and >18 years) for analysis. Data were analyzed by sex and age groups using t-tests and linear regression.

RESULTS

Sella and parasellar parameters did not differ by sex. SL steadily increased from 8.5 ± 1.2 mm to 11.5 ± 1.6 mm throughout development. SDp and SDm increased from 6.0 ± 0.9 mm to 9.3 ± 1.4 mm and 9.0 ± 1.6 mm to 14.4 ± 1.8 mm during maturation, with significant interval growth from ages 16-18 to adult (p < 0.01). ID displayed significant growth from ages 0-3 to 4-7 (18.0 ± 2.4 mm to 20.7 ± 1.9 mm; p = 0.002) and ICD from ages 0-3 to 8-11 (12.0 ± 1.8 mm to 13.5 ± 2.1 mm; p < 0.001), without further significant interval growth. SSP was not seen in patients < 3, but was 100% by ages 8-11. SSTs progressed from conchal/presellar (60% at ages 4-7) to sellar/postsellar (80% at adulthood).

CONCLUSION

The sella and parasellar regions have varied growth patterns with development. Knowledge of the expected maturation of key anterior skull base structures may augment surgical planning in younger patients.