Endoscopic endonasal skull base surgery in the pediatric population

Pediatric Orbital and Skull Base Pathology

Pediatric orbital and skull base pathologies encompass a spectrum of inflammatory, sporadic, syndromic, and neoplastic processes that require a broad and complex clinical approach for both medical and surgical treatment. Given their complexity and often multicompartment involvement, a multidisciplinary approach for diagnosis, patient and family counseling, and ultimately treatment provides the best patient satisfaction and clinical outcomes. Advances in minimally invasive surgical approaches, including endoscopic endonasal and transorbital approaches allows for more targeted surgical approaches through smaller corridors beyond more classic transcranial or transracial approaches.

Craniopharyngioma: A comprehensive review of the clinical presentation, radiological findings, management, and future Perspective

Craniopharyngioma (CP) is a rare intracranial tumor arising from the epithelial remnants of Rathke's pouch, most frequently originating in the sellar/parasellar region. Histologically, CP is a benign low-grade tumor (WHO grade 1) with two distinct phenotypes: adamantinomatous CP (ACP) and papillary CP (PCP). Craniopharyngioma constitutes 1-3% of all primary intracranial tumors in adults and 5-10 % of intracranial tumors in children. The annual incidence ranges from 0.13 to 2 per 100,000 population per year with no gender predilection. Due to its unique anatomical locations, the most frequently reported clinical manifestations are headache, visual impairment, nausea/vomiting, and endocrine deficiencies resulting in sexual dysfunction in adults and growth failure in children. Growth hormone deficiency is the most predominant endocrinological disturbance associated with craniopharyngioma. Computed tomography (CT) is gold standard to detect calcifications in CP tissue (found in 90 % of these tumors). Magnetic Resonance Imaging (MRI) further characterizes craniopharyngiomas and helps to narrow down the differential diagnoses. In almost all craniopharyngioma cases, surgery is indicated to: establish the diagnosis, relieve mass-related symptoms, and remove as much tumor as is safely possible. Recent neurosurgical technical advances, including innovative surgical approaches, detailed radiotherapy protocols, targeted therapy, replacement of lost hormonal functions and quality of life all have the potential to improve the outcome of patients with craniopharyngioma. In this article, we present extensive literature on craniopharyngioma clinical presentation, radiological findings, management, and future prospective. The present article helps to identify further research areas that set the basis for the management of such a complex tumor.

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.

Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 1, general recommendations

Tumours of the anterior part of the pituitary gland represent just 1% of all childhood (aged <15 years) intracranial neoplasms, yet they can confer high morbidity and little evidence and guidance is in place for their management. Between 2014 and 2022, a multidisciplinary expert group systematically developed the first comprehensive clinical practice consensus guideline for children and young people under the age 19 years (hereafter referred to as CYP) presenting with a suspected pituitary adenoma to inform specialist care and improve health outcomes. Through robust literature searches and a Delphi consensus exercise with an international Delphi consensus panel of experts, the available scientific evidence and expert opinions were consolidated into 74 recommendations. Part 1 of this consensus guideline includes 17 pragmatic management recommendations related to clinical care, neuroimaging, visual assessment, histopathology, genetics, pituitary surgery and radiotherapy. While in many aspects the care for CYP is similar to that of adults, key differences exist, particularly in aetiology and presentation. CYP with suspected pituitary adenomas require careful clinical examination, appropriate hormonal work-up, dedicated pituitary imaging and visual assessment. Consideration should be given to the potential for syndromic disease and genetic assessment. Multidisciplinary discussion at both the local and national levels can be key for management. Surgery should be performed in specialist centres. The collection of outcome data on novel modalities of medical treatment, surgical intervention and radiotherapy is essential for optimal future treatment.

CSF leak after pediatric endoscopic endonasal expanded approaches: a series review

PURPOSE

Endoscopic endonasal approaches in the pediatric population pose specific challenges. Management of postoperative cerebrospinal fluid [CSF] leak is probably the major concern. The purpose of the present investigation is to describe and analyze the incidence of postoperative CSF leaks in our pediatric series of endoscopic endonasal approaches.

METHODS

This is a retrospective analysis, case review of our institutional series. Descriptive statistical parameters and bivariate correlations are analyzed.

RESULTS

Twenty-one patients have been operated through endoscopic approaches in our series. Four patients showed a postoperative CSF leak needing a revision surgery; these cases are described in further detail. Approaches expanded beyond the sellar area and non-sellar pneumatization of the sphenoid sinus were significantly associated with a higher risk of postoperative CSF leak.

CONCLUSIONS

CSF leak incidence after endoscopic endonasal approaches is higher in pediatric patients than in adult series. Anatomic and pathologic factors add complexity to these approaches in children. Multilayer closure is advisable to prevent and treat this complication.

Reconstruction of the Anterior Skull Base Using the Nasoseptal Flap: A Review

The nasoseptal flap is a workhorse reconstructive option for anterior skull base defects during endonasal surgery. This paper highlights the versatility of the nasoseptal flap. After providing a brief historical perspective, this review will focus on the relevant primary literature published in the last ten years. We will touch upon new applications of the flap, how the flap has been modified to expand its reach and robustness, and some of the current limitations. We will conclude by discussing what the future holds for improving upon the design and use of the nasoseptal flap in anterior skull base reconstruction.

The development of a pediatric skull base team: how, where and why?

PURPOSE OF REVIEW

The purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.

RECENT FINDINGS

Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.

SUMMARY

The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.

Neuroendoscopy: intraventricular and skull base tumor resection in children

During the last 30 years, the neurosurgeons have witnessed a revolution in the practice of interventricular surgery. The advent of neuroendoscopy at the end of the 1980s has allowed a minimally invasive management of a very large series of pathologies in pediatric neurosurgery ranging from hydrocephalus to arachnoid cyst to intraventricular tumors. The progresses in the management of hydrocephalus, intracranial cyst, and the fluid filled collection nevertheless has been more rapid and radical due to the simpler equipment that is necessary to perform this kind of surgery. The intraventricular tumors instead have been addressed in a slower way, and for many years, the only endoscopic procedure that was allowed on interventricular tumors was a biopsy associated with the management of hydrocephalus. Only very small tumors have been considered operable for complete removal during many years due to the limitations of the neuroendoscopic equipment and to the small calibers of the working channel. More recently, the advent of new devices and new surgical techniques are offering new perspectives on the possibility of intraventricular tumor surgery in children. In this review, we describe the historical perspective of the learning curve of intraventricular tumor surgery under neuroendoscopic control and try to offer a view of the future perspective in the removal of larger intraventricular tumors, analyzing the main indications for intraventricular endoscopic tumor surgery. We offer as well an historical perspective of the evolution of skull base surgery and endonasal transsphenoidal approach for skull-based tumors in children. This kind of surgery that has acquired widespread acceptance for many pathologies in adult age has diffused more slowly in pediatric neurosurgery due to the anatomical limitation observed in these age range. Also in this field, the slow evolution of the technique and of the technology available to neurosurgeons has allowed a very significant expansion of indication for the minimally invasive removal of skull base tumors in children.

Outcomes of Endoscopic Resection in Pediatric Skull Base Chordoma: A Systematic Review

The endoscopic approach has been recommended as a primary option for treating chordomas, and it is associated with better resection rates and fewer surgical complications than transcranial surgery. This review aimed to assess the long-term consequences and evidence in the current literature regarding the endoscopic approach's efficacy in treating skull-base chordoma in children. A systematic review was conducted based on the PubMed, Web of Science, and EMBASE databases to examine the clinical outcomes of endoscopic endonasal surgery for pediatric skull base chordoma tumors. The review included studies published in English that employed specific research designs and reported on pediatric patients with skull base chordoma. Of the 268 studies initially considered, 25 met our eligibility criteria and were included in the final analysis. The average age of the patients was 11.5 years, with approximately equal number of males and females. The endoscopic endonasal approach (EEA) was the most commonly used modality. Gross total resection (GTR) was achieved in 62.7% of patients, while 18.09% had a subtotal resection (STR), and 13.83% had near-total resection only. Most patients showed significant to moderate improvement from their baseline condition and had no recurrence during their follow-up. Our findings further endorse that the endoscopic approach is a viable primary treatment option for pediatric skull base chordoma.

Triple Layer Oronasal Fistula Repair Using Local Endonasal Flaps: Case Series of Three Patients

Oronasal fistula (ONF) is a common complication encountered after palatoplasty. Repair is indicated when symptoms impact speech and swallowing. In spite of the variety of surgical approaches described to repair these defects, recurrence rates remain high. Traditionally, successful closure is said to be achieved in using a double-layered approach due to the three-dimensional aspect of the defect. The extent of the fistula into the nasal cavity has incited an increased curiosity in using local endonasal flaps. In recent years, endonasal reconstructive procedures have seen increased interest and application, from cranial base defect repairs to orbital reconstruction and beyond. The nasoseptal (NSF) and inferior turbinate flaps (ITF) possess a robust arterial supply and an exceptional reach with excellent results demonstrated in large defect repair. However, the use of these flaps in ONF repair is scarcely discussed in the literature, and their effectiveness is relatively undetermined. In this manuscript, we present a series of three patients who underwent a triple layer ONF closure, with the oral portion incorporating a turn-in mucosal flap plus a local palate rotation flap or greater palatine artery pedicled-rotation flap, and a NSF or an ITF for the nasal portion of the defect.

Pediatric Endoscopic Endonasal Skull Base Surgery: A Retrospective Review Over 11 Years

OBJECTIVE

To show the safety and efficacy of the endoscopic endonasal approach (EEA) for skull base surgery in pediatric patients through descriptive analysis of cases over an 11-year period.

METHODS

The study comprised 94 patients undergoing EEA for skull base surgery, between January 2007 and June 2018, at 2 tertiary pediatric hospitals. Descriptive statistics are presented regarding the presentation, intraoperative details, and complications.

RESULTS

Over the study period, 130 surgeries were performed in 94 patients: 94 primary surgeries and 36 reoperations. The mean patient age was 13.8 years and 48.9% of patients were female. Presenting signs/symptoms included endocrinopathies (56.4%), vision abnormalities (37.2%), and cranial nerve deficits (20.2%). EEA alone was used in 95.7% of primary surgeries and 91.7% of reoperations. Diseases treated included craniopharyngioma (18.1%), pituitary adenoma (17.0%), Rathke cleft cyst (13.8%), chordoma (9.6%), osteosarcoma (5.3%), juvenile nasopharyngeal angiofibroma (4.3%), skull base fracture (4.3%), and encephalocele (3.2%). A lumbar drain was used in 20.2% of primary surgeries and 25% of reoperations. A nasoseptal flap was used in 36.2% of primary surgeries and 25% of reoperations. Postoperative complications included cerebrospinal fluid leak (12.8%), sinusitis (7.4%), bacterial meningitis (3.2%), and carotid artery injury in 1 reoperation.

CONCLUSIONS

EEA for anterior cranial base disease is safe and efficacious in pediatric patients and can be used to treat many of the rare and heterogenous diseases that arise in this anatomic location. Management strategies and rates of sinonasal and intracranial complications including cerebrospinal fluid leak rate are similar to those reported in adult cohorts.

Neurosurgical Treatment and Outcome of Pediatric Skull Base Lesions: A Case Series and Review of the Literature

INTRODUCTION

Pediatric skull base lesions occur rarely and are of various etiologies. Traditionally, open craniotomy has been the treatment of choice; however, nowadays, endoscopic approaches are increasingly applied. In this retrospective case series, we describe our experience in treating pediatric skull base lesions and provide a systematic overview of the literature on the treatment and outcome of pediatric skull base lesions.

METHODS

We conducted a retrospective data collection of all pediatric patients (<18 years) treated for a skull base lesion at the Division of Pediatric Neurosurgery, University Children's Hospital Basel, Switzerland, between 2015 and 2021. Descriptive statistics and a systematic review of the available literature were additionally conducted.

RESULTS

We included 17 patients with a mean age of 8.92 (±5.76) years and nine males (52.9%). The most common entity was sellar pathologies (n = 8 47.1%), with craniopharyngioma being the most common pathology (n = 4, 23.5%). Endoscopic approaches, either endonasal transsphenoidal or transventricular, were used in nine (52.9%) cases. Six patients (35.3%) suffered from transient postoperative complications, while in none of the patients these were permanent. Of the nine (52.9%) patients with preoperative deficits, two (11.8%) showed complete recovery and one (5.9%) partial recovery after surgery. After screening 363 articles, we included 16 studies with a total of 807 patients for the systematic review. The most common pathology reported in the literature confirmed our finding of craniopharyngioma (n = 142, 18.0%). The mean PFS amongst all the studies included was 37.73 (95% CI [36.2, 39.2]) months, and the overall weighted complication rate was 40% (95% CI [0.28 to 0.53] with a permanent complication rate of 15% (95% CI [0.08 to 0.27]. Only one study reported an overall survival of their cohort of 68% at five years.

CONCLUSION

This study highlights the rarity and heterogeneity of skull base lesions in the pediatric population. While these pathologies are often benign, achieving GTR is challenging due to the deep localization of the lesions and eloquent adjacent structures, leading to high complication rates. Therefore, skull base lesions in children require an experienced multidisciplinary team to provide optimal care.

Minimally invasive endoscopic approaches to pediatric skull base pathologies

OBJECTIVE

Endoscopic endonasal approaches to pediatric skull base lesions are rare, challenging, and present distinct considerations from adult pathology. In this study, we describe our endoscopic technical approach to various skull base lesions demonstrating the efficacy and nuances of these approaches in pediatric patients.

METHODS

Pediatric patients underwent endoscopic approach for skull base lesions from January of 2015 to April of 2021 were included in the study. Presenting symptoms, indications for surgery, surgical outcomes, intraoperative and postoperative complications, length of hospital stay, and length of follow-up were documented.

RESULTS

A total of 18 patients (median age 12, age-range 1-15, 53% male) underwent 19 endoscopic transsphenoidal procedures. The pathologies included craniopharyngioma (N = 5), biopsy for an unknown disease (n = 2; orbital meningioma and pituitary lymphocytic hypophysitis), pituitary adenoma (N = 2; ACTH-secreting and non-functional), Rathke's cleft cyst (n = 2), CSF leak repairs (n = 2; post-traumatic and spontaneous meningocele), juvenile nasopharyngeal angiofibroma (n = 3, 1 patient had 2 procedures) and rhabdomyosarcoma (n = 1). GTR was achieved in 11 out of 15 procedures (73.3%). Out of 10 patients with a sellar lesion, 6 patients had intraoperative CSF leak (60%). No patients experienced post-operative CSF leak. The median follow-up for all patients was 14 months (1-36 months).

CONCLUSION

Anterior and middle skull base pathology in pediatric patients can be effectively operated via an endoscopic approach across a wide variety of patient ages and conditions. Minimally invasive techniques with middle turbinate and nasal septum preservation can be achieved without compromising outcomes. A wide variety of surgical repair strategies can be successfully utilized.

Incidence of Sinus Inflammation After Endoscopic Skull Base Surgery in the Pediatric Population

BACKGROUND

The extended endonasal approach has been utilized in the resection of anterior skull base lesions in the pediatric population. There are unique challenges to these patients in the post-operative setting, including patient compliance with medical therapy and post-operative debridements, and a smaller nasal airway that may increase propensity toward scarring. Our objective for this study is to evaluate the incidence of post-operative radiographic inflammation in this patient population using the Lund-Mackay (LM) score.

METHODS

A single-center, retrospective review of pediatric patients undergoing endoscopic approach to the skull base between 2009 and 2021 was performed. Demographic and clinicopathologic data and pre- and post-operative imaging were analyzed. One-way ANOVA followed by Tukey multiple pairwise comparisons statistical tests were used to compare mean LM scores between groups.

RESULTS

Seventy-two patients (52 males, 20 females) were identified with a median follow-up of 27 months. All patients underwent an extended endonasal approach for resection of skull base lesions. The mean LM scores were compared between pre-operative MRI, first post-operative MRI > 30 days after surgery, and most recent post-operative MRI. One-way ANOVA was performed with significant differences noted between the groups (p < 0.001). Tukey multiple pairwise comparisons test was then performed and noted significant differences between the pre-operative and first post-operative LM (p < 0.0001) and the first post-operative and most recent LM (p < 0.0001). There was no significant difference noted between the pre-operative LM score and most recent LM score (p = 0.14).

CONCLUSION

Despite concerns regarding possible subsequent development of chronic rhinosinusitis following endoscopic skull base surgery in pediatric patients, the current study suggests that transient radiographic evidence of sinus inflammation can be seen up to six months postoperatively, which appears to resolve by approximately two years after surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Sinonasal Symptom Outcomes following Endoscopic Anterior Cranial Base Surgery in the Pediatric Population

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.

Anatomic Parameters and Growth of the Pediatric Skull Base: Endonasal Access Implications

Objectives: Endoscopic endonasal anterior skull base surgery has expanding use in the pediatric population, but the anatomy of pediatric patients can lead to limitations. This study aims to characterize the important anatomical implications of the pediatric skull base using computed tomography (CT) scans. Design: Retrospective analysis Setting: Tertiary academic medical center Participants: 506 patients aged 0-18 who had undergone maxillofacial and or head CTs between 2009-2016. Methods: Measurements included piriform aperture width, nare to sella distance (NSD), sphenoid pneumatization, olfactory fossa depth, lateral lamella cribriform plate angles, and intercarotid distances (ICD) at the superior clivus and cavernous sinus. These patients were then subdivided into 3 age groups adjusting for sex. ANCOVA models were fit comparing between all age groups and by sex. Results: Piriform aperture width, NSD, sphenoid sinus pneumatization as measured using lateral aeration and anterior sellar wall thickness, olfactory fossa depth, and ICD at the cavernous sinus was significantly different among all age groups (P<0.0001). Our results show that mean piriform aperture width increased with each age group. The mean olfactory fossa depth also had consistent age dependent growth. In addition, ICD at the cavernous sinus showed age dependent changes. When comparing by sexes, females consistently showed smaller measurements. Conclusion: The process of skull base development is age and sex dependent. During preoperative evaluation of pediatric patients for skull base surgery piriform aperture width, sphenoid pneumatization in both the anterior posterior and lateral directions, and ICD at the cavernous sinus should be carefully reviewed.  

Clinical outcomes of coblation-assisted pediatric endoscopic endonasal skull base surgery

BACKGROUND

Pediatric skull base surgeries are confined by developmental and anatomical issues. Radiofrequency coblation integrates the functions of ablation, suction, and coagulation with the ability to dissolve tissues with limited thermal injury, making it an ideal instrument for pediatric skull base surgery. We sought to evaluated the clinical outcomes of coblation-assisted pediatric endoscopic skull base surgery.

METHODS

Medical records of patients under 15 years of age undergoing endoscopic skull base surgery were retrospectively reviewed. The estimated blood loss (EBL)/operating time (OT) and Wormald grade were used for intraoperative blood loss grading.

RESULTS

Generally, 28 patients (17 males, 11 females) with an average age of 8.4 ± 4.2 years, (range, 11 months to 15 years old) were included. Coblation was applied in 20 patients for mucosa coagulation and handling, cartilage removal, tumor separation and excision. The primary diagnoses included juvenile nasopharyngeal angiofibroma (n = 5), traumatic cerebrospinal fluid (CSF) leak (n = 6), congenital meningoencephalocele (n = 6) and miscellaneous sinonasal and skull base neoplasm (n = 11). The application of coblation was related with a significant decrease in EBL/OT (34.1 ± 17.5 vs 56.3 ± 22.6 ml/h, p = 0.048) and Wormald grade (5.7 ± 1.5 vs 6.9 ± 2.0, p = 0.038), compared with the traditional techniques. All surgical procedures were uneventful. No significant difference in postoperative complications, including cranial nerve dysfunction and CSF rhinorrhea were documented during the follow-up period (average, 34.7 ± 4.4 months).

CONCLUSION

We suggested the coblation be a safe and effective instrument for pediatric skull base surgery.

Combined Neuroendoscopic Techniques in the Management of Pediatric Brain and Skull Base Tumors: A Single-Institutional Case Series

BACKGROUND

Central nervous system tumors encompass the leading cause of cancer-related death in the pediatric population. Neuroendoscopic techniques have been optimized over the years, becoming an important tool for the management of brain tumors. Our study aims to review the indications for neuroendoscopic procedures and the feasibility of combined interventions.

METHODS

This is a single-center, self-adjudicated, retrospective experience. Inclusion criteria consisted of pediatric patients (≤18 years old) who underwent management of brain tumor or related diseases with the employment of neuroendoscopy.

RESULTS

A total of 47 patients undergoing 51 procedures met inclusion criteria. The mean age was 9.8 ± 4.6 years, and the majority were female (55.3%). Common indications for endoscopic intervention were hydrocephalus management (n = 24; 16 endoscopic third ventriculostomies and 9 septostomies), tumor biopsy (n = 19), cyst fenestration (n = 16), and tumor resection (n = 9). In one third of the cases, combined interventions occurred during a single operative session. Hydrocephalus was successfully managed in 74.4% of cases; tumor biopsy confirmed the diagnosis in 95.8% of cases, and gross total resection was achieved in 88.9% of cases. Cyst fenestration required reintervention in 3 cases: one case associated with initial cyst enlargement and 2 cases with the development of new tumor cysts separated from the originally fenestrated cyst. The overall complication rate was 6.3%, with only one major safety event, which was successfully managed.

CONCLUSIONS

Neuroendoscopy is an important minimally invasive tool for diagnosing and treating pediatric patients with brain tumors, permitting to address multiple problems in a single surgery.

Pediatric pituitary adenomas are more aggressive, more likely to be hormone producing and are more difficult to cure than adult pituitary adenomas: case series and systematic literature review

PURPOSE

Pediatric pituitary adenomas (pPAs) are uncommon. Thus, their presentation and outcomes after treatment are less well-understood than those of pituitary adenomas in adulthood (aPAs).

METHODS

A retrospective chart review was conducted for all patients who underwent endoscopic endonasal transsphenoidal surgery (EETS) for pPA at NewYork-Presbyterian Hospital/Weill Cornell Medicine (NYP/WCM) from 2005-2020. Eleven patients were identified, and information pertaining to age, sex, adenoma characteristics, procedural details, and outcomes was reviewed. A systematic review of the literature was also performed to compare outcomes of EETS versus microscopic endonasal transsphenoidal surgery (METS) for pPA.

RESULTS

From 2005-2020, 11 patients underwent EETS for pPA at NYP/WCM. Mean age at operation was 14.9 ± 2.7 years, and 5 patients (45.5%) were male. 10 adenomas (90.9%) were hormone-producing. Of the functional adenomas, 8 (80.0%) were PRL-secreting and 2 (20.0%) were GH-secreting. Maximum adenoma diameter (MAD) ranged from 1.2-5.1 cm, with a median of 1.55 cm. Cavernous sinus invasion (CSI) occurred in 2 patients with macroprolactinoma. Gross total resection (GTR) was achieved in 10 (90.9%). Biochemical remission occurred in 5/10 (50.0%). Post-operative complications were documented in 8 cases (72.7%) and included diabetes insipidus, hypopituitarism, sinusitis, weight gain, cerebrospinal fluid leak, meningitis, and hydrocephalus. Systematic literature review of 105 microscopic and 175 endoscopic cases revealed high frequency of hormone-producing tumors (83.6%) and similar rates of GTR (82.4% vs 85.1%) and biochemical cure (75.8% vs 64.3%).

CONCLUSIONS

pPAs are more likely to be hormone producing and may be more aggressive and difficult to cure than aPAs. EETS is an effective treatment, although complication rates may be higher than in adult populations.

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.

Multiple Endocrine Neoplasia in Childhood: An Update on Diagnosis, Screening, Management and Treatment

Multiple endocrine neoplasia (MEN) is a group of heterogenous syndromes characterized by the occurrence of two or more endocrine gland tumors in a patient or related individuals in the same family. They are inherited in an autosomal dominant fashion and are highly penetrant. There are three types of MEN syndromes: MEN type 1 (MEN1), MEN type 2 (MEN2), and MEN type 4 (MEN4). MEN2 is further divided into MEN2A, MEN2B (formerly known MEN3), and familial medullary thyroid carcinoma (FMTC). Although MEN syndromes are rare, it is crucial to identify individuals at risk for potentially life-threatening neoplasias. This review article provides an update on each MEN syndrome, its genetics, diagnosis, and management in children.

Extended Neuroendoscopic Endonasal Approach for Resection of Craniopharyngioma in Children

Objective

To explore the surgical approach and technique of neuroendoscopic endonasal resection of pediatric craniopharyngiomas and to further evaluate its safety and effect in children.

Methods

The clinical data of 8 children with craniopharyngiomas who were surgically treated by neuroendoscopy through an extended endonasal approach in our center from 2018 to 2021 were retrospectively analyzed. The related surgical approach and technique were evaluated to improve the surgical results and further reduce the surgical complications when removing craniopharyngioma in children.

Results

All 8 patients achieved a gross-total resection of the tumor under neuroendoscopy. Postoperatively, 2 cases of transient hyperthermia and 4 cases of transient hyper- and/or hyponatremia occurred within the first 2 weeks, all of which were quickly controlled. Seven patients had symptoms of diabetes insipidus to varying degrees after the operation, and 4 of them improved within 1–3 months after surgery, but 3 cases still needed oral pituitrin. There were no cases of coma or death, leakage of cerebrospinal fluid, or severe electrolyte imbalance after surgery. During the postoperative follow-up of 3 months to 2 years, no tumor recurrence was found. Among the 7 patients who suffered postoperative neuroendocrine deficiencies, 3 patients were found to be temporary during the follow-up, but 4 patients still required hormone replacement therapy. Particularly, postoperative visual deterioration and olfactory defect that occurred in patients were all improved during follow-up periods. In addition, 4 cases of obesity were noted at the last follow-up.

Conclusions

Extended neuroendoscopic endonasal resection of craniopharyngiomas may be used as a safe and effective approach for children. Due to the poor pneumatization of the sphenoid sinus and worse compliance of treatment in children, surgical techniques of exposing the sellar region, removing the tumor, and reconstructing the skull base, as well as postoperative management of patients was proposed. However, due to the limited surgical cases in the study, the surgical safety and effects of the extended neuroendoscopic endonasal approach for children with craniopharyngiomas need to be further studied in the future.

Outcomes in Pediatric Endoscopic Skull Base Surgery: A Systematic Review

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.

Endoscopic Endonasal Treatment of a Sinonasal Vascular Neoplasm in the Postnatal Period: Case Report and Review of Literature

OBJECTIVES

Congenital vascular lesions commonly present in the head and neck, and most are managed conservatively. Location and rapid growth, however, may necessitate surgical intervention. Endoscopic endonasal surgery (EES) in the pediatric population has emerged as a viable option in treating sinonasal and skull base lesions. Utilizing these techniques in newborns carries unique challenges. The objective of this report is to describe the successful use of direct intralesional embolization followed by endoscopic endonasal resection of a venous malformation in a postnatal patient.

METHODS

We reviewed the case reported and reviewed the pertinent literature.

RESULTS

A 6-week-old infant was found to have a large right-sided sinonasal lesion confirmed as a venous malformation. Rapid growth, impending orbital compromise, and potential long-term craniofacial abnormalities demanded the need for urgent surgical intervention. Risk of bleeding was mitigated with direct intralesional embolization. Immediately afterward, the patient underwent endoscopic endonasal resection of the lesion. EES in the very young presents multiple challenges both anatomically and behaviorally. A multidisciplinary approach lead to a successful outcome.

CONCLUSION

We report a case of a 6-week-old infant, the youngest reported patient to the authors' knowledge, who successfully underwent direct intralesional embolization followed by endoscopic endonasal resection of a sinonasal vascular malformation. This report highlights the challenges of this technique in the very young and demonstrates it as a viable treatment strategy for sinonasal vascular anomalies in this population.

Characteristics and overall survival in pediatric versus adult pituitary adenoma: a National Cancer Database analysis

OBJECTIVE

Pituitary adenomas in the pediatric population are extremely rare, resulting in limited information in the literature on these patients. In this study, data from the National Cancer Database (NCDB) to compare pituitary adenoma clinical presentations, treatment management patterns, and overall survival between pediatric and adult patients.

METHODS

The NCDB was queried for all cases of histologically confirmed pituitary adenoma treated between 2004 and 2015. Patients were primarily stratified as either pediatric (< 18 years) or adult (≥ 18 years). Patient demographics/socioeconomics and resulting outcomes were then compared.

RESULTS

1893 pediatric and 77,993 adult patients with pituitary adenomas were evaluated. Average tumor size for pediatric and adult patients was 13.6 ± 13.2 mm and 20.1 ± 13.1 mm, respectively (p < 0.001). Pediatric patients were more likely to undergo gross total resection, less likely to receive adjuvant radiation, more likely to receive medical therapy, more likely to undergo active surveillance, and exhibited improved 5-year and 10-year overall survival (OS) (all p < 0.001). Temporal analysis demonstrated a significant increase in endoscopic approach over time (from 48 to 65%) in the pediatric population (R² = 0.722, p = 0.03). On univariate analysis in the pediatric population, African American race compared to Caucasians (HR: 5.85, 95% CI 1.79-19.2, p < 0.003), patients with government insurance compared to those with private insurance (HR: 5.07, 95% CI 1.31-19.6, p < 0.02) and uninsured patients compared to those with private insurance (HR: 14.4, 95% CI 2.41-86.5, p < 0.003) were associated with decreased OS. Lastly, patients who underwent GTR had improved OS compared to those who underwent subtotal resection (HR: 0.08, 95% CI 0.008-0.93, p < 0.04) in the pediatric population.

CONCLUSIONS

Compared to adults, children with pituitary adenomas more commonly underwent GTR, less frequently underwent adjuvant radiotherapy, more frequently underwent medical management and active surveillance, and had improved survival. Temporal analysis demonstrated increasing utilization of the endoscopic approach for surgical treatment of pediatric and adult pituitary adenoma patients.

LEVEL OF EVIDENCE

Level III.

Endoscopic Skull Base Surgery in the Pediatric Population

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.

Cerebrospinal fluid leakage repair of various grades developing during endoscopic transnasal transsphenoidal surgery

Objectives

We describe the strategy used to repair intraoperative leaks of various grades and define factors for preventing postoperative cerebrospinal fluid leakage (CSF) after surgery via the endoscopic endonasal transsphenoidal approach (EETA).

Study design

Retrospective chart review at a tertiary referral center.

Methods

Patients who underwent surgery via EETA from January 2009 to May 2020 were retrospectively reviewed. Intraoperative CSF leakage was graded 0–3 in terms of the dural defect size; various repairs were used depending on the grade.

Results

A total of 777 patients underwent 869 operations via EETA; 609 (70.1%) experienced no intraoperative CSF leakage (grade 0) but 260 (29.9%) did. Leakage was of grade 1 in 135 cases (15.5%), grade 2 in 83 (9.6%), and grade 3 in 42 (4.8%). In 260 patients with intraoperative CSF leakage, a buttress was wedged into the sellar defect site in 178 cases (68.5%) and a pedicled flap was placed in 105 cases (40.4%). Autologous fat (108 cases, 41.5%) and a synthetic dural substitute (91 cases, 35%) were used to fill the dead space of the sellar resection cavity. Postoperative CSF leakage developed in 21 patients: 6 of grade 1, 7 of grade 2, and 8 of grade 3. Buttress placement significantly decreased postoperative leakage in grade 1 patients (p = 0.041). In patients of perioperative leakage grades 2 and 3, postoperative CSF leakage was significantly reduced only when both fat and a buttress were applied (p = 0.042 and p = 0.043, respectively).

Conclusion

A buttress prevented postoperative CSF leakage in grade 1 patients; both fat and buttress were required by patients with intraoperative leakage of grades 2 and 3.

Nasoseptal Flap for Skull Base Reconstruction in a Three-Year-Old Child With Nasofrontal Meningoencephalocele

Congenital anterior skull base defects with meningoencephaloceles causing nasal obstruction and cerebrospinal fluid (CSF) rhinorrhea are rare clinical entities. Traditionally, skull base defects have been repaired via a bifrontal craniotomy. With the introduction of pediatric endoscopic instrumentation, more of these lesions are accessible via an intranasal endoscopic approach, even in the infant population. However, due to the rarity of pediatric meningoencephaloceles, there is a lack of data demonstrating the successful adaptation of endoscopic skull base techniques to the pediatric population. In this report, we present a case of a pediatric frontonasal meningoencephalocele with an anterior skull base defect in a 3-year-old child that was successfully addressed transnasally following 4 failed transcranial approaches. The case highlights the importance of a thorough preoperative evaluation of the surgical approach as well as interdisciplinary management of these patients at a young age. Congenital anterior skull base defects with meningoencephaloceles and CSF leaks are rare clinical entities. Hence, an interdisciplinary approach is vital including experienced pediatricians, otolaryngologists, and neurosurgeons to evaluate the ideal surgical method on an individual basis. The transnasal endoscopic technique has been shown to be minimally invasive, efficient, and safe to apply even to the infant population which could positively be demonstrated in this case.

Intercarotid artery distance in the pediatric population: Implications for endoscopic transsphenoidal approaches to the skull base

OBJECTIVE

Comprehensive quantitative evaluation of the intercarotid artery distance (ICD) in the pediatric population has not been sufficiently explored. This study aims to measure the minimal ICDs at multiple levels of the skull base to assess changes in the ICD during development.

METHODS

Measurement of the ICDs between the paired paraclival, parasellar, and paraclinoid segments of the internal carotid artery (ICA) was performed on coronal MRI from 540 patients ranging from 0 to 17 years old (n = 30 for each age). Comparison of these indices in the very young (0-5 years, Group 1) and young (6-17 years, Group 2) patients, and assessment of the degree of sphenoid sinus pneumatization was employed.

RESULTS

The narrowest ICD was located at the paraclinoid ICAs in the vast majority of cases (89.44%). When comparing the ICDs in very young age patients with the ICDs of 17 years old subjects, a statistically significant difference was found at the paraclival (ages 0-5), parasellar (ages 0-2), and paraclinoid (ages 0-4) ICDs (p < 0.05). Comparison of the ICDs between the intergroups (Group 1 and 2) also demonstrated a statistically significant difference (p < 0.0001). Pneumatization of the sphenoid sinus was initially noted to start at 3 years of age, and there were no patients with a non-pneumatized sphenoid sinus identified after 7 years of age in our cohort.

CONCLUSION

Measurement of ICDs at multiple levels provides a valuable reference for EEA procedures in the pediatric population. While the ICD may be largely stable in the pediatric population after 5 years of age, additional anatomic factors may restrict transsphenoidal access in very young patients (0-5 years).

Operative Procedure in a Suprasellar Paediatric Lesion of the Optic Chiasm with Hydrocephalus Caused by a Papillary Glioneuronal Tumour

INTRODUCTION

Paediatric tumours in the sellar and parasellar regions present clinical and surgical challenges due to anatomical position and behaviour. We illustrate a rare case which caused obstructive hydrocephalus.

CASE PRESENTATION

The study included a 14-year-old girl with a glioneuronal tumour (40 mm) originating from the optic chiasm, obliterating the aqueduct, with consequent triventricular hydrocephalus. The patient underwent extended endoscopic endonasal surgery and repair of the skull-base deficiency using a multi-layer technique with fascia lata. The 12-month follow-up showed no complications or recurrences, with recovery in visual acuity.

CONCLUSION

The immediate placement of external ventricular drainage, in combination with an extended trans-sphenoidal approach, is a safe and feasible option to treat suprasellar paediatric lesions with hydrocephalus.

First experience with augmented reality neuronavigation in endoscopic assisted midline skull base pathologies in children

INTRODUCTION

Endoscopic skull base approaches are broadly used in modern neurosurgery. The support of neuronavigation can help to effectively target the lesion avoiding complications. In children, endoscopic-assisted skull base surgery in combination with navigation systems becomes even more important because of the morphological variability and rare diseases affecting the sellar and parasellar regions. This paper aims to analyze our first experience on augmented reality navigation in endoscopic skull base surgery in a pediatric case series.

PATIENTS AND METHODS

A retrospective review identified seventeen endoscopic-assisted endonasal or transoral procedures performed in an interdisciplinary setting in a period between October 2011 and May 2020. In all the cases, the surgical target was a lesion in the sellar or parasellar region. Clinical conditions, MRI appearance, intraoperative conditions, postoperative MRI, possible complications, and outcomes were analyzed.

RESULTS

The mean age of our patients was 14.5 ± 2.4 years. The diagnosis varied, but craniopharyngiomas (31.2%) were mostly represented. AR navigation was experienced to be very helpful for effectively targeting the lesion and defining the intraoperative extension of the pathology. In 65% of the oncologic cases, a radical removal was proven in postoperative MRI. The mean follow-up was 89 ± 79 months. There were no deaths in our series. No long-term complications were registered; two cerebrospinal fluid (CSF) fistulas and a secondary abscess required further surgery.

CONCLUSION

The implementation of augmented reality to endoscopic-assisted neuronavigated procedures within the skull base was feasible and did provide relevant information directly in the endoscopic field of view and was experienced to be useful in the pediatric cases, where anatomical variability and rarity of the pathologies make surgery more challenging.

Outcomes of Endoscopic Versus Open Skull Base Surgery in Pediatric Patients

OBJECTIVE/HYPOTHESIS

To characterize the pathology and outcomes of skull base surgery in the pediatric population by open versus endoscopic surgical approach.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective review of pediatric patients (<18 years) who underwent skull base surgery for nonmalignant disease from May 2000 to August 2019 was performed. Patient demographics, pathology, and operative characteristics by surgical approach were recorded and analyzed. Patients with a combined endoscopic/open approach were classified as open for the analysis.

RESULTS

Eighty-two pediatric skull base patients were identified with a mean age of 11.3 years (standard deviation 5.2). A purely endoscopic approach was used in 63 (77%) patients, a purely open approach was used in nine (11%) patients, and a combined open/endoscopic approach was used in 10 (12%) patients. The all-cause complication rate was 9.8%. There was no statistically significant difference in rate of complications between patients with an open versus endoscopic approach for resection (15.8% vs. 7.9%; P = .379). Risk of having a complication did not significantly vary by patient age. The odds of having a complication with an open approach was not statistically significant in a multivariable model adjusted for age, sex, race, intraoperative cerebrospinal fluid leak, tracheostomy requirement, and vascular flap use (odds ratio 2.76, 95% confidence interval 0.28-26.94; P = .383).

CONCLUSIONS

Our retrospective study demonstrates a similar risk of complication for open versus endoscopic approach to resection in pediatric skull base patients at our institution. Safety and feasibility of the endoscopic approach has previously been demonstrated in children, and this is the first study to directly compare outcomes with open approaches.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:996-1001, 2021.

Congenital Anterior Skull Base Encephaloceles: Long-Term Outcomes After Transnasal Endoscopic Reconstruction

BACKGROUND

Congenital intranasal encephaloceles (ECs) are rare malformations of the pediatric age, complex to diagnose and treat, above all if associated with genetic syndromes or concomitant dysmorphisms. The aims of the study were to report our experience in managing nasal ECS in children, to evaluate the efficacy and safety of the transnasal endoscopic repair, and to analyze in an overall way the surgical long-term outcomes. Moreover, we sought to contribute to the debate on pathogenesis of ECs, investigating possible related risk factors described in the literature.

METHODS

A retrospective analysis was performed of pediatric nasal ECs managed with a transnasal endoscopic approach at a tertiary referral center through clinical follow-up and telephone survey.

RESULTS

Twenty-three patients with nasal ECs fitted the criteria of the study. Mean age at surgery was 5 years (69 months) and the mean follow-up was 59 months. The clinical presentation is described in detail, with particular emphasis on syndromic cases. Of 23 patients, 17 had an isolated EC, and in 4 patients, a malformation syndrome was associated. EC recurred in 2/23 patients (8.7%) after surgical correction, necessitating a revision procedure. No perioperative complications or long-term sequelae were noted in the entire population.

CONCLUSIONS

Endonasal endoscopic management of congenital ECs is feasible in children, although regular long-term follow-up is essential. Furthermore, the surgical approach does not seem to affect patients' development and quality of life, although more studies and validated questionnaires are needed. No recurrent risk factors were observed able to justify a certain etiologic relation.

Intracranial Intradural Vascular Injury during Endoscopic Endonasal Transsphenoidal Surgery: A Case Report and Literature Review

Background  Transsphenoidal surgery (TSS) is a procedure for sellar or midline masses in the skull base. Among the reported complications are iatrogenic vascular injuries; that are rare, yet they carry devastating outcomes, with an incidence of injury between 0.34 and 2.6%. The cavernous internal carotid artery is the most commonly injured. However, intradural arterial injuries are much less reported with challenging management. We report a rare incident of intradural arterial injury during TSS, and we compared our management to the summarized few cases reported in the literature Case Report  We report a 43-year-old female who had a recurrent planum sphenoidal meningioma. She underwent trans-nasal transsphenoidal endoscopic resection that was complicated with intraoperative bleeding due to an injury to the anterior communicating artery that was challenging to control, resulted in a bilateral loss of flow in A1 segments of anterior cerebral artery and required endovascular management. The patient had a good recovery postoperatively without the typical picture of ACA syndrome. Conclusion  Intradural arterial injury is exceedingly rare in TSS, with no clear standard of care for the management. Collateral blood supply allows definitive management with minimal morbidity. Identifying the risk factors beforehand, as well as performing such cases in a well-resourced center, are crucial elements of safety.

Reconstruction of pediatric skull base defects: A retrospective analysis emphasizing the very young

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.

Pediatric sinonasal and skull base lesions

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.

The expanded endonasal approach in pediatric skull base surgery: A review

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.

Endonasal Endoscopic Surgery for Pediatric Sellar and Suprasellar Lesions: A Systematic Review and Meta-analysis

OBJECTIVES

The advent of endonasal endoscopic skull base surgery (ESBS) has redefined the management of pediatric sellar and suprasellar lesions. To date, the outcomes of these procedures have not been systematically reviewed. This study performed a systematic review with meta-analysis of surgical outcomes for pediatric patients undergoing ESBS for sellar and suprasellar lesions.

DATA SOURCES

PubMed (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and Cochrane Library (Wiley).

REVIEW METHODS

Articles reporting on pediatric patients undergoing ESBS for craniopharyngiomas, pituitary adenomas, and Rathke's cleft cysts were reviewed. The primary outcome was postoperative cerebrospinal fluid (CSF) leak. Secondary outcomes included endocrine, visual, and other complications.

RESULTS

Twenty-five articles reporting on 554 patients were included. Overall postoperative CSF leak rate was 8.6%, with tumor-specific rates of 10.6% in craniopharyngiomas, 6.5% in pituitary adenomas, and 7.2% in Rathke's cleft cysts (P > .05). Older studies demonstrate higher postoperative CSF leak rates as compared with more recent studies (12.5% vs 6.1%, P = .0082). Younger children (8.9-12.6 years old) experienced a higher rate of postoperative CSF leaks as compared with older children (13.0-16.6 years old; 12.9% vs 4.9%, P = .0016). Additional postoperative complications included diabetes insipidus (26.7%), hypopituitarism (46.6%), visual deficits (2.6%), meningitis (3.4%), and weight gain (3.4%).

CONCLUSION

ESBS for pediatric sellar and suprasellar lesions is overall an effective management approach with an increasingly favorable risk-benefit profile. Younger children may be more susceptible to postoperative CSF leak as compared with older pediatric patients. Tumor type does not appear to be an independent risk factor for postoperative CSF leak in this population.

Pedicled nasoseptal flap reconstruction for craniopharyngiomas in pediatric patients

PURPOSE

Though the use of the pedicled nasoseptal flap (NSF), a reconstructive technique used after endoscopic endonasal approaches (EEA) for resection of craniopharyngiomas, has been shown to reduce the occurrence of post-operative cerebrospinal fluid (CSF) leaks in adults, less is known about its use in pediatric populations, specifically in children under the age of 7. The goal of this retrospective cohort study is to determine the viability of the pedicled NSF for pediatric patients.

METHODS

Retrospective review of 12 pediatric patients (ages 2-16) undergoing 13 NSF reconstructions after resection of craniopharyngiomas. Radioanatomic analysis of computed tomography (CT) scans was utilized to classify the pneumatization of the sphenoid sinus depending on the thickness of the sphenoid bone margin. Intercarotid distances were measured from magnetic resonance imaging (MRI) scans to assess the feasibility of this reconstruction technique in pediatric patients.

RESULTS

At the time of surgery, all patients were noted to have adequate NSF length and width. No post-operative high-flow CSF leaks were found within the group. Lack of pneumatization of the sphenoid sinus and narrow intercarotid distances in the youngest of patients did not lead to negative clinical outcomes.

CONCLUSIONS

Based on our results and experience, the pedicled nasoseptal flap is a viable reconstructive option after EEA in the pediatric population, including even the youngest of patients. In these patients, a narrowed window between the intercarotid arteries and the lack of pneumatization of the sphenoid sinus present a challenge that can be overcome by using stereotactic navigation and advanced endoscopic techniques.

Perioperative nasal and paranasal sinus considerations in transsphenoidal surgery for pituitary disease

Endoscopic endonasal skull base surgery has emerged as the treatment modality of choice for a range of skull base lesions, particularly pituitary adenomas. However, navigation and manipulation of the nasal corridor and paranasal sinuses requires that surgeons are aware of effective techniques to maximize patient outcomes and avoid sinonasal morbidity postoperatively. This paper is a narrative review aimed to provide an updated and consolidated report on the perioperative management of the nasal corridor and paranasal sinuses in the setting of endoscopic skull base surgery for pituitary disease. Anatomic variants and common surgical techniques are discussed. Post-operative complications are evaluated in detail. Understanding the structural implications of the endonasal approach to the sphenoid is crucial to optimization of the surgical outcomes. We propose guidelines for perioperative management of endoscopic endonasal skull base surgery for pituitary diseases. Standardized treatment algorithms can improve patient satisfaction, and increase the comparability and the quality of reported information across research studies.

Endoscopic Endonasal Resection of Meckel's Cave Epidermoid Cysts: Case Discussion and Literature Review

Meckel's cave (MC) epidermoid cysts are relatively uncommon lesions. In cases where surgical excision is indicated, resection is often carried out via a frontosphenotemporal craniotomy from an anterolateral approach or a temporal craniotomy with or without a petrosectomy for a lateral corridor; both of these routes are associated with brain retraction and potential neurovascular injury. The anterior location of MC in the middle cranial fossa makes safe access via posterior fossa-based approaches—such as the retrosigmoid approach—challenging as well. Here, we present the cases of two patients diagnosed with epidermoid cysts in MC who underwent surgical resection via an endoscopic endonasal transpterygoid approach. Near-total resection was achieved in both cases, with only mild transient neurologic disturbances postoperatively. Radiographically, no evidence of residual disease was noted in either patient. We further review the nuances of an extended endoscopic endonasal approach to these lesions.

The limits of endoscopic endonasal approaches in young children: a review

INTRODUCTION

The endoscopic endonasal approach (EEA) provides visualization of four deep surgical corridors (transcribiform, transtubercular, transsellar, and transclival) with superior illumination and specialized deep-reaching instruments, as compared to microscopic techniques. Several studies have evaluated EEAs in children but do not stratify for the very young of age, whose particularly small nares and developmental anatomy may limit endonasal instrumentation.

METHODOLOGY

A comprehensive review of EEAs in infants and children to age 4 was performed to determine the limitations in this age group.

RESULTS

Eighteen studies were identified describing this approach for pediatric patients and the surgical caveats and limitations were reviewed. In very small children, CSF leaks, meningioencephaloceles, tumors of the anterior skull base, and lesions at the rostral cervical spine have been successfully treated endonasally. While newer studies advocate using 2.7-mm diameter (18-cm length) lenses, 4-mm diameter rigid lenses have been used without technical difficulty. The youngest patient in whom an EEA was used was a 6-week-old for a dermoid resection. Some have advocated that due to the small nares, approaches via bilateral entry are optimal for multiple instruments, however, others, including authors of a series of 28 repaired CSF leaks demonstrate successful single nare access.

DISCUSSION

EEAs are associated with less blood loss, are less likely to hinder normal growth of the skull and midface, and allow for the resection of even malignant lesions. Despite the limitations of the frontal, ethmoid, and sphenoid sinuses before age 3, reports have not documented insurmountable difficulty with EEAs even in infants. 2.7-mm diameter endoscopes are favored unilaterally or bilaterally to treat both benign and malignant lesions and preserve the young patient's facial anatomy better than older methods. Ever improving technology has facilitated the use of this approach in patients it would otherwise be infeasible for in the past, but it still cannot overcome the anatomical constraints of certain young patients in which this approach remains unindicated. Patient selection is therefore of utmost importance and the risks and benefits of more extensive approaches in these cases must be considered.

Extraordinary case presentations in pediatric pituitary adenoma: report of 6 cases

Pediatric pituitary adenomas (PPAs) are rare neoplasms with a propensity for unusual presentations and an aggressive clinical course. Here, the authors describe 6 highly atypical PPAs to highlight this tendency and discuss unexpected management challenges.A 14-year-old girl presented with acute hemiparesis and aphasia. MRI revealed a pituitary macroadenoma causing internal carotid artery invasion/obliteration without acute apoplexy, which was treated via emergent transsphenoidal resection (TSR). Another 14-year-old girl developed precocious galactorrhea due to macroprolactinoma, which was medically managed. Several years later, she re-presented with acute, severe, bitemporal hemianopia during her third trimester of pregnancy, requiring emergent induction of labor followed by TSR. A 13-year-old boy was incidentally diagnosed with a prolactinoma after routine orthodontic radiographs captured a subtly abnormal sella. An 18-year-old male self-diagnosed pituitary gigantism through a school report on pituitary disease. A 17-year-old boy was diagnosed with Cushing disease by his basketball coach, a former endocrinologist. A 12-year-old girl with growth arrest and weight gain was diagnosed with Cushing disease, which was initially treated via TSR but subsequently recurred and ultimately required 12 operations, 5 radiation treatments involving 3 modalities, bilateral adrenalectomy, and chemotherapy. Despite these efforts, she ultimately died from pituitary carcinoma.

Neuronavigation-Guided Endoscopic Endonasal Drainage of Pediatric Anterior Cranial Base Epidural and Subdural Empyema

In children, epidural and/or subdural intracranial empyema can complicate frontal sinusitis or pansinusitis. The standard transcranial approach used to treat epidural or subdural empyema has many drawbacks, but these can be avoided with an endoscopic expanded endonasal approach (EEA). To support the feasibility and advantages of this approach, we report the successful drainage through endoscopic EEA of a bifrontal empyema caused by an intracranial extension of pansinusitis. Our case and the ones previously reported in the literature establish well that endoscopic EEA offers several advantages over the standard craniotomy. Hence, EEA should be considered as an alternative to the transcranial approach when surgically draining anterior skull base empyema resulting from pansinusitis in children.

The endoscopic endonasal approach for pediatric craniopharyngiomas: the key lessons learned

PURPOSE

The aim of this study is to highlight the role of the endoscopic endonasal approach (EEA) in pediatric craniopharyngiomas by reviewing our experience and the key lessons learned from the application of this approach in children.

METHODS

Between 1998 and 2017, 12 pediatric craniopharyngiomas were treated via EEA at our institution. Demographic data, preoperative assessment, tumor features, surgical results, complications, and recurrences were analyzed.

RESULTS

Visual defects were the most frequent presenting sign. Seven craniopharyngiomas were infradiaphragmatic, and five were supradiaphragmatic. The EEA was successfully performed in all cases with no complication related to children's sinonasal anatomy. Gross total resection (GTR) rate was of 75%. Endocrinological disturbances improved in one case (20%) and worsened in three (60%). New onset of diabetes insipidus was observed in four (36%) children. Visual defect improved in 91% of cases, with no new postoperative deficit. Postoperative cerebrospinal fluid (CSF) leak occurred in one patient (8%). Three patients (27%) experienced tumor regrowth, and one craniopharyngioma recurred (mean follow-up, 78 months).

CONCLUSIONS

The EEA offers a straight route to the sellar-suprasellar, making it the ideal approach for pediatric infradiaphragmatic craniopharyngiomas. In supradiaphragmatic craniopharyngiomas, the extended EEA provides a clearer and close-up visualization of the tumor-hypothalamus interface, which can grant better results in terms of quality of life. The pediatric skull base anatomy should not represent a contraindication for the endoscopic technique. Larger series encompassing a wider spectrum of pediatric craniopharyngiomas are needed to further support the benefits of this surgical approach.

Endonasal endoscopic skullbase surgery in children

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.

Pediatric pituitary adenomas

BACKGROUND

Pediatric pituitary adenomas are a rare medical entity that makes up a small portion of intracranial tumors in children and adolescents. Although benign, the majority of these lesions are secreting functional tumors with the potential for physiological sequela that can profoundly affect a child's development.

FOCUS OF REVIEW

In this review, we discuss the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to treat these tumors. The management of pituitary tumors requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver comprehensive care.

Pediatric craniopharyngioma

BACKGROUND

Craniopharyngioma has historically been recognized to be a formidable pathology primarily due to its proximity to critical neurovascular structures and the challenging surgical corridors that surgeons have tried to reach this lesion.

FOCUS OF REVIEW

In this work, we review the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to craniopharyngiomas. The management of craniopharyngiomas requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver the most comprehensive and safest surgical resection with minimal postoperative morbidity.