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Di Gioia S, Cosseron S, Simon F, Couloigner V, Luscan R. Endoscopic endonasal repair of bilateral choanal atresia in a 1200 g preterm infant: Is it feasible? (With video). Am J Otolaryngol 2023; 44:103749. [PMID: 36577169 DOI: 10.1016/j.amjoto.2022.103749] [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: 10/30/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Bilateral choanal atresia (CA) is a rare congenital anomaly, that causes neonatal respiratory distress. No consensus exists regarding the most appropriate surgical approach in low-birth weight preterm infants. CASE REPORT We present (with video) the case of a male born at 29 weeks' gestation, 1200 g, affected by bilateral CA. He was successfully treated with an endoscopic transnasal approach performed on day 4 of life which allowed a very early extubation. Otologic instruments and 2.7 mm wide endoscope were used to be able to operate in very narrow nasal cavities. Thulium LASER® was used to limit bleeding. At the follow-up visit, four months after surgery, the neochoana was widely patent. DISCUSSION In low-birth weight preterm infants, endoscopic transnasal surgery (ETS) may be considered technically not feasible or with a high risk of early restenosis. With early ETS, we were able to avoid the morbidity of a prolonged intubation and sedation. CONCLUSION Bilateral CA is a life threatening and challenging clinical entity, particularly difficult to treat in low-birth preterm infants. Early surgery to reduce intubation and sedation is preferable, but requires experienced teams with a surgical technique and instruments tailored to the narrowness of the nasal cavity.
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Affiliation(s)
- Stefano Di Gioia
- Department of Paediatric Otolaryngology, AP-HP, Hôpital Necker-Enfants Malades, F-75015 Paris, France; Department of Otolaryngology-Head and Neck Surgery, University Hospital of Verona, 37124 Verona, Italy
| | - Sarah Cosseron
- Department of Paediatric Otolaryngology, AP-HP, Hôpital Necker-Enfants Malades, F-75015 Paris, France; Department of Otolaryngology-Head and Neck Surgery, Centre Hospitalier Sud Francilien, F-91100 Corbeil-Essonnes, France
| | - François Simon
- Department of Paediatric Otolaryngology, AP-HP, Hôpital Necker-Enfants Malades, F-75015 Paris, France; Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
| | - Vincent Couloigner
- Department of Paediatric Otolaryngology, AP-HP, Hôpital Necker-Enfants Malades, F-75015 Paris, France; Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
| | - Romain Luscan
- Department of Paediatric Otolaryngology, AP-HP, Hôpital Necker-Enfants Malades, F-75015 Paris, France; Université Paris Cité, Faculté de Médecine, F-75006 Paris, France.
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Endoscopic Skull Base Surgery in Children. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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Riley CA, Soneru CP, Overdevest JB, Otten ML, Gudis DA. Pediatric sinonasal and skull base lesions. World J Otorhinolaryngol Head Neck Surg 2020; 6:118-124. [PMID: 32596657 PMCID: PMC7296510 DOI: 10.1016/j.wjorl.2020.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 01/18/2020] [Indexed: 12/13/2022] Open
Abstract
Pediatric skull base lesions are complex and challenging disorders. Safe and comprehensive management of this diverse group of disorders requires the expertise of an experienced multidisciplinary skull base team. Adult endoscopic skull base surgery has evolved due to technologic and surgical advancements, multidisciplinary team approaches, and continued innovation. Similar principles continue to advance the care delivered to the pediatric population. The approach and management of these lesions varies considerably based on tumor anatomy, pathology, and surgical goals. An understanding of the nuances of skull base reconstruction unique to the pediatric population is critical for successful outcomes.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Christian P Soneru
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Jonathan B Overdevest
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Marc L Otten
- Department of Neurological Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - David A Gudis
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
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London NR, Rangel GG, Walz PC. The expanded endonasal approach in pediatric skull base surgery: A review. Laryngoscope Investig Otolaryngol 2020; 5:313-325. [PMID: 32337363 PMCID: PMC7178460 DOI: 10.1002/lio2.369] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Surgery of the pediatric skull base has multiple unique challenges and has seen recent rapid advances. The objective of this review is to assess key issues in pediatric skull base surgery (SBS), including anatomic limitations, surgical approaches, reconstruction techniques, postoperative care, complications, and outcomes. DATA SOURCES PubMed literature review. REVIEW METHODS A review of the literature was conducted to assess the challenges, recent advances, and reported outcomes in pediatric SBS. RESULTS The pediatric skull base presents multiple anatomic challenges, including variable patterns of pneumatization, narrow piriform aperture width, and narrow intercarotid distance at the level of the cavernous sinus but not the superior clivus. These issues may be particularly challenging in patients less than 2 years of age. Endoscopic endonasal approaches in the sagittal and coronal plane have been applied to the pediatric skull base while open approaches may still be necessary in the setting of extensive intracranial or orbital disease, as well as disease lateral to critical neurovascular structures. While the nasoseptal flap was initially called into question for pediatric cases, it has been shown through multiple reports to be a feasible and robust reconstructive option. Complications and outcomes often depend upon the pathology. In children, response to noxious stimuli, ability to avoid Valsalva, and adherence to nasal precautions is variable. The use of lumbar drains is more common in pediatric than adult patients. CONCLUSION While the pediatric skull base presents unique challenges, outcomes data support that endoscopic endonasal approaches are a pertinent surgical technique in appropriately selected patients. LEVEL OF EVIDENCE 3a.
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Affiliation(s)
- Nyall R. London
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Otolaryngology‐Head and Neck SurgeryJohns Hopkins School of MedicineBaltimoreMarylandUSA
- National Institute on Deafness and Other Communication DisordersNIHBethesdaMarylandUSA
| | - Gustavo G. Rangel
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
| | - Patrick C. Walz
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
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Deopujari CE, Shah NJ, Shaikh ST, Karmarkar VS, Mohanty CB. Endonasal endoscopic skullbase surgery in children. Childs Nerv Syst 2019; 35:2091-2098. [PMID: 31079184 DOI: 10.1007/s00381-019-04167-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/17/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The role of endonasal endoscopic approach for pathologies in the paediatric population is evolving and has still not been accepted as standard of care in neurosurgery. It represents a challenge in terms of narrow access, instrument manipulation and adequate reconstruction of defects. We have described our experience in 49 cases from a single neurosurgical unit in paediatric skull base surgeries through this approach over the last 12 years. MATERIAL AND METHODS A case series of 59 paediatric skull base surgeries in 49 children through endoscopic endonasal route over the last 12 years is presented. The age ranges from 4 months to 18 years. Out of 49 cases, 22 cases were of craniopharyngiomas, 8 cases of pituitary adenomas, 5 cases with CSF rhinorrhea, 5 cases with meningoencephalocele, 3 cases of Rathke's cleft cysts, 2 cases of odontoidectomy and 4 miscellaneous cases viz. mucocele, hypothalamic glioma, esthesioneuroblastoma and epidermoid. CSF leaks were repaired with free graft in the initial years and by vascularized flap more recently. RESULTS The goal of surgery was achieved in all but two cases in whom the tumour excision was unsatisfactory due to failure of the cyst wall to collapse after decompression. Extent of tumour excision was not compromised by the choice of this approach. Revision surgery for CSF leak was required in three patients. Local vascularized nasoseptal flap has been possible even in very young patients and has now become the standard for reconstruction. CONCLUSION In spite of the challenges posed by small nostrils and ill-developed sinuses in the paediatric age group, surgery from endoscopic endonasal corridor is possible to be carried out successfully in selected cases.
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Affiliation(s)
| | - Nishit J Shah
- Department of ENT, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Salman T Shaikh
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Vikram S Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Chandan B Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
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Shah N, Deopujari C, Bommakanti V. The reconstruction of skull base defects in infants using pedicled nasoseptal flap-a review of four cases. Childs Nerv Syst 2019; 35:2157-2162. [PMID: 30968177 DOI: 10.1007/s00381-019-04132-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 03/18/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Benign lesions of the skull base are common in the paediatric population, and are usually congenital in aetiology. Majority of these lesions are treated transcranially exposing the patients to a number of risks. Although endoscopic endonasal surgery (EES) helps avoid many of these potential morbidities, CSF leak with its attendant complication remains a big concern. This study reports the use of the Hadad flap in the reconstruction of skull base defects in infants to prevent this problem. The study was conducted on four infants with a mean age of 7 months, who underwent repairs for CSF leaks associated with congenital lesions like meningocele or meningoencephalocele, using the Hadad flap. Of the four patients, three cases were revision cases and one was primary where the patients presented with complaints such as nasal obstruction and watery nasal discharge. Post surgery, the infants were monitored for a mean period of 23 months and no major complications or recurrent CSF drainage were observed. Minor complications that were observed include vestibulitis and crusting in the nose. The utility of the Hadad flap in the reconstruction of skull base defects in the paediatric age group has been controversial while its utility in infants has not been studied in literature so far. We report here in our series four infant patients in whom we believe that the nasal septum and the skull base will develop proportionally to each other, hence lowering the chances of a short flap and eliminating the occurrence of future complications. CONCLUSION The nasoseptal flap is an effective and safe technique for reconstructing skull base defects in infancy. It can be concluded that this technique does not have any potential effect on septal or craniofacial growth as the flap is harvested only on one side with normal mucosal cover on the other side. There is no posterior septectomy or any form of bony or cartilaginous resection that is performed, hence avoiding any effects on bony growth. No studies have been published in literature so far and to the best of our knowledge, this is the first report describing the efficacy of the nasoseptal flap in infants.
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Affiliation(s)
- Nishit Shah
- ENT Department, Bombay Hospital, Mumbai, India.
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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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Nation J, Schupper AJ, Deconde A, Levy M. CSF leak after endoscopic skull base surgery in children: A single institution experience. Int J Pediatr Otorhinolaryngol 2019; 119:22-26. [PMID: 30660855 DOI: 10.1016/j.ijporl.2019.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The endoscopic expanded endonasal approach (EEA) has been shown to be a safe and effective surgical technique in the resection of pediatric skull base lesions. Cerebrospinal fluid (CSF) leaks are among the most common complications of this approach. Here we review skull base resections using EEA in pediatric patients at our single institution, to identify potential risk factors for this surgical complication. METHODS A retrospective chart review was conducted on pediatric patients at our single institution for patients 19 years-old and under, who underwent an EEA for resection of a skull base tumor. RESULTS Thirty-nine pediatric patients (ages 1-19 years) with 8 different tumor pathologies underwent an EEA for resection of their skull base tumors. 21 patients experienced an intraoperative CSF leak, of which 10 (48%) were "high-flow" leaks and 11 (52%) were "low-flow" leaks. Nasoseptal flaps were only used to repair the intraoperative "high flow" leaks (n = 10), and "low flow" and "no leaks" were repaired with allograft and fat. No patients experienced a post-operative CSF leak. CONCLUSION In our pediatric series, the skull base repair algorithm of using an NSF only in cases of "high flow" intraoperative leaks was effective, and no post-operative CSF leaks occurred. Not using an NSF in cases of "low-flow" or "no leak" cases allows for decreased anatomical disruption in the growing patient.
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Affiliation(s)
- Javan Nation
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery University of California San Diego, Division of Pediatric Rady Children's Hospital San Diego, USA; University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Alexander J Schupper
- Department of Neurosurgery, University of California San Diego, Division of Pediatric Neurosurgery Rady Children's Hospital San Diego, USA; University of California San Diego School of Medicine, La Jolla, CA, USA.
| | - Adam Deconde
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery University of California San Diego, Division of Pediatric Rady Children's Hospital San Diego, USA
| | - Michael Levy
- Department of Neurosurgery, University of California San Diego, Division of Pediatric Neurosurgery Rady Children's Hospital San Diego, USA; University of California San Diego School of Medicine, La Jolla, CA, USA
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Soyka MB, Serra C, Regli L, Meier E, Holzmann D. Long-term olfactory outcome after nasoseptal flap reconstructions in midline skull base surgery. Am J Rhinol Allergy 2018; 31:334-337. [PMID: 28859712 DOI: 10.2500/ajra.2017.31.4463] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The nasoseptal flap (NSF) is a universally used surgical technique to cover defects of the skull base after extended sinonasal surgery. Long-term follow-up of complications, sequelae, and smell function is largely unknown. OBJECTIVE The main objective of this study was to investigate monorhinal olfaction after transsphenoidal skull base surgery. METHODS Patients who underwent skull base surgery for midline lesions (craniopharyngioma and pituitary tumors) by using a NSF, also referred to as the Haddad flap, were assessed for their long-term outcome. Endoscopic examination was conducted and the bilateral "Sniffin' Sticks" test was performed before surgery. Each side was tested separately in the postoperative follow-up consultation. RESULTS Twenty patients were included in the study. No flap failures were observed. One anterior perforation and one small posterior septal perforation were found during long-term follow-up. None of the patients had nasal breathing impairment, whereas two patients had nose bleeds. A significant decrease in olfactory function was observed on the flap donor side in four patients (20%) compared with that observed in one patient (5%) on the opposite side. CONCLUSION NSF reconstructions for midline lesions were efficient and safe in the long term. Olfactory impairment on the donor side was frequently encountered. Although subclinical, these findings justified a monorhinal smell testing before surgery, which possibly prevented bilateral smell impairment in patient with preexisting single-sided olfactory loss.
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Affiliation(s)
- Michael B Soyka
- 1Department Otorhinolaryngology, Head and Neck Surgery, University and University Hospital Zurich, Zurich, Switzerland
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Nation J, Schupper AJ, Deconde A, Levy M. Pediatric Endoscopic Endonasal Approaches for Skull Base Lesions in the Very Young: Is It Safe and Effective? J Neurol Surg B Skull Base 2018; 79:574-579. [PMID: 30456027 DOI: 10.1055/s-0038-1645854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/02/2018] [Indexed: 10/17/2022] Open
Abstract
Introduction The fully endoscopic expanded endonasal approach (EEA) has been shown to be safe and efficacious in pediatric patients. However, in the very young patient (ages six and under), the anatomical challenge of working through a small nasal corridor is problematic. The ability to repair the skull base and use a nasoseptal flap (NSF) has also been called into question. Here, we review skull base resections using EEA in patients aged 6 years and younger. Methods A retrospective chart review was conducted on pediatric patients age 6 years and younger who underwent EEA skull base resections over a 3-year period (June 2014 through June 2017). Results Eight children aged 6 and under with seven tumor pathologies underwent an EEA for the resection of their skull base tumors, with a mean follow-up of 1.45 years. Only chordoma cases required multiple-staged resections. There are no tumor recurrences to date. A high-flow intraoperative cerebrospinal fluid (CSF) leak was encountered in three cases, and there were no postoperative CSF leaks. CSF leaks were effectively repaired with NSFs. One patient suffered from postoperative hypopituitarism, one patient experienced recurrent epistaxis secondary to turbinate destruction by the tumor, and one patient expired 8 months postresection secondary to metastatic disease. Conclusion In our case series, EEA for skull base tumors in children aged 6 and under was a safe and effective surgical approach. Skull base defects are able to be effectively addressed with typical repairs including NSFs. Larger studies are warranted to further investigate this technique in this pediatric population.
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Affiliation(s)
- Javan Nation
- Department of Surgery, Division of Otolaryngology, University of California San Diego, San Diego, California, United States.,Rady Children's Hospital San Diego, San Diego, California, United States
| | - Alexander J Schupper
- University of California San Diego School of Medicine, San Diego, California, United States
| | - Adam Deconde
- Department of Surgery, Division of Otolaryngology, University of California San Diego, San Diego, California, United States
| | - Michael Levy
- Department of Neurosurgery, University of California San Diego, San Diego, California, United States.,Rady Children's Hospital San Diego, San Diego, California, United States
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Duek I, Pener-Tessler A, Yanko-Arzi R, Zaretski A, Abergel A, Safadi A, Fliss DM. Skull Base Reconstruction in the Pediatric Patient. J Neurol Surg B Skull Base 2018; 79:81-90. [PMID: 29404244 DOI: 10.1055/s-0037-1615806] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Introduction Pediatric skull base and craniofacial reconstruction presents a unique challenge since the potential benefits of therapy must be balanced against the cumulative impact of multimodality treatment on craniofacial growth, donor-site morbidity, and the potential for serious psychosocial issues. Objectives To suggest an algorithm for skull base reconstruction in children and adolescents after tumor resection. Materials and Methods Comprehensive literature review and summary of our experience. Results We advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity. Free soft-tissue transfer in microvascular technique is the mainstay for reconstruction of large, three-dimensional defects, involving more than one anatomic region of the skull base, as well as defects involving an irradiated field. However, to reduce total operative time, intraoperative blood loss, postoperative hospital stay, and donor-site morbidity, locoregional flaps are better be considered the flap of first choice for skull base reconstruction in children and adolescents, as long as the flap is large enough to cover the defect. Our "workhorse" for dural reconstruction is the double-layer fascia lata. Advances in endoscopic surgery, image guidance, alloplastic grafts, and biomaterials have increased the armamentarium for reconstruction of small and mid-sized defects. Conclusions Skull base reconstruction using locoregional flaps or free flaps may be safely performed in pediatrics. Although the general principles of skull base reconstruction are applicable to nearly all patients, the unique demands of skull base surgery in pediatrics merit special attention. Multidisciplinary care in experienced centers is of utmost importance.
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Affiliation(s)
- Irit Duek
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Alon Pener-Tessler
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ravit Yanko-Arzi
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Arik Zaretski
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Avraham Abergel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ahmad Safadi
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Stapleton AL, Tyler-Kabara EC, Gardner PA, Snyderman CH, Wang EW. Risk factors for cerebrospinal fluid leak in pediatric patients undergoing endoscopic endonasal skull base surgery. Int J Pediatr Otorhinolaryngol 2017; 93:163-166. [PMID: 28109490 DOI: 10.1016/j.ijporl.2016.12.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine the risk factors associated with cerebrospinal fluid (CSF) leak following endoscopic endonasal surgery (EES) for pediatric skull base lesions. METHODS Retrospective chart review of pediatric patients (ages 1 month to 18 years) treated for skull base lesions with EES from 1999 to 2014. Five pathologies were reviewed: craniopharyngioma, clival chordoma, pituitary adenoma, pituitary carcinoma, and Rathke's cleft cyst. Fisher's exact tests were used to evaluate the different factors to determine which had a statistically higher risk of leading to a post-operative CSF leak. RESULTS 55 pediatric patients were identified who underwent 70 EES's for tumor resection. Of the 70 surgeries, 47 surgeries had intraoperative CSF leaks that were repaired at the time of surgery. 11 of 47 (23%) surgeries had post-operative CSF leaks that required secondary operative repair. Clival chordomas had the highest CSF leak rate at 36%. There was no statistical difference in leak rate based on the type of reconstruction, although 28% of cases that used a vascularized flap had a post-operative leak, whereas only 9% of those cases not using a vascularized flap had a leak. Post-operative hydrocephalus and perioperative use of a lumbar drain were not significant risk factors. CONCLUSIONS Pediatric patients with an intra-operative CSF leak during EES of the skull base have a high rate of post-operative CSF leaks. Clival chordomas appear to be a particularly high-risk group. The use of vascularized flaps and perioperative lumbar drains did not statistically decrease the rate of post-operative CSF leak.
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Affiliation(s)
- Amanda L Stapleton
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, United States.
| | - Elizabeth C Tyler-Kabara
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, United States
| | - Carl H Snyderman
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, United States; Department of Neurological Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, United States
| | - Eric W Wang
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, United States
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Hanba C, Svider PF, Shkoukani MA, Sheyn A, Jacob JT, Eloy JA, Folbe AJ. Pediatric pituitary resection: characterizing surgical approaches and complications. Int Forum Allergy Rhinol 2016; 7:72-79. [PMID: 27626904 DOI: 10.1002/alr.21840] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/04/2016] [Accepted: 07/22/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although there has been extensive study evaluating adult pituitary surgery, there has been scant analysis among children. Our objective was to evaluate a population-based resource to characterize nationwide trends in surgical approach, hospital stay, and complications among children undergoing pituitary surgery. METHODS The Kids' Inpatient-Database (KID) files (2009/2012) were evaluated for pituitary gland excisions. Procedure, patient demographics, length of inpatient stay, inpatient costs, hospital setting, and surgical complications were analyzed. RESULTS A weighted incidence of 1071 cases were analyzed; the majority (77.6%) underwent transsphenoidal resections. These patients had significantly decreased hospital costs and lengths of stay. Patients undergoing transfrontal approaches had significantly greater rates of postoperative diabetes insipidus (DI) (66.5%), panhypopituitarism (38.8%), hydrocephalus, and visual deficits. Among transsphenoidal patients, males had greater rates of postoperative hydrocephalus (5.5%) and panhypopituitarism (17.5%) than females, and patients ≤10 years old had greater rates of these 2 complications (14.5%, 19.4%, respectively) as well as DI (61.3%). CONCLUSION A greater proportion of children undergo transfrontal approaches for pituitary lesions than in their adult counterparts. This difference may harbor a potential to influence future sellar resection approaches in children toward a transsphenoidal operation when surgically feasible. Patients undergoing transfrontal procedures have greater risks for many intraoperative and postoperative complications relative to individuals undergoing transsphenoidal resections. Among patients undergoing transsphenoidal approaches, males had significantly greater rates of postoperative hydrocephalus and panhypopituitarism, and younger children had greater rates of postoperative DI, hydrocephalus, and panhypopituitarism. These data reinforce the need for greater vigilance in the postoperative care of younger children undergoing transsphenoidal surgery.
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Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Mahdi A Shkoukani
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Anthony Sheyn
- Department of Otolaryngology-Head and Neck Surgery, The University of Tennessee Health Science Center School of Medicine, Memphis, TN.,LeBonheur Children's Hospital, Department of Pediatric Otolaryngology, Memphis, TN
| | - Jeffrey T Jacob
- Michigan Head and Spine Institute, Novi, MI.,William Beaumont Health System, Royal Oak, MI
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, NJ.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ
| | - Adam J Folbe
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI
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