Pediatric Cranial Vault and Skull Base Fractures

Cranial vault and skull base fractures in children are distinctly different from those seen in adults. Pediatric skull fractures have the benefit of greater capacity to remodel; however, the developing pediatric brain and craniofacial skeleton present unique challenges to diagnosis, natural history, and management. This article discusses the role of surgical treatment of these fractures, its indications, and techniques.

Use of patient-specific 3D printed models in pre-operative counseling for pediatric skull base surgery

OBJECTIVES

Pediatric cranial base pathology is anatomically complex and surgical treatment is oftentimes difficult to conceptualize for patients and their families. Three-dimensional (3D) models of the sinuses and cranial base have the potential to enhance patient understanding in numerous domains. Our objective is to assess the use of 3D models in pre-operative parental and patient counseling prior to endoscopic endonasal skull base surgery in the pediatric population.

METHODS

A survey was designed to assess parent and patient-perceived utility of 3D-printed models in surgical counseling prior to pediatric skull base surgery.

RESULTS

A total of 10 patients were included. The median age was 9 years (range = 5 months-15 years). Pathology included juvenile nasopharyngeal angiofibroma (JNA) (N = 4), fibrous dysplasia of the maxilla and sphenoid (N = 1), juvenile ossifying fibroma (N = 1), nasal dermoid (N = 2, one with intracranial extension), encephalocele (N = 1), and parapharyngeal ectopic glial tissue (N = 1). Nearly all parents agreed or strongly agreed that 3D printed models were helpful in explaining the patient's skull base pathology (N = 10), surgical plan (N = 10), and possible complications (N = 9). All parents strongly agreed that 3D models should be used routinely in pre-operative counseling for endoscopic endonasal surgery. According to a majority of parents, patients older than 4 years old found the models helpful in understanding their pathology (75%) and surgery (88%).

CONCLUSION

By allowing direct three-dimensional visualization of the target pathology, 3D models serve as a useful adjunct in enhancing patient comprehension of the pathologic entity, planned surgery, and potential complications prior to pediatric endoscopic endonasal skull base surgery.

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.

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.

Simulation of Pediatric Anterior Skull Base Anatomy Using a 3D Printed Model

OBJECTIVE

The pediatric skull base may present anatomic challenges to the skull base surgeon, including limited sphenoid pneumatization and a narrow nasal corridor. The rare nature of pediatric skull base pathology makes it difficult to gain experience with these anatomic challenges. The objective of this study was to create a 3-dimensionally (3D) printed model of the pediatric skull base and assess its potential as a training tool.

METHODS

Twenty-eight participants at various stages of training and practice were included in our study. They completed a pre- and postdissection questionnaire assessing challenges with endoscopic endonasal skeletonization of the carotid arteries and sella face using the 3D printed model.

RESULTS

The majority of participants had completed a skull base surgery fellowship (60.7%), were <5 years into practice (60.7%), and had <10 cases of pediatric skull base experience (82.1%). Anticipated challenges included limitation of maneuverability of instruments (71.4%), narrow nasal corridor and nonpneumatized bone (57.1%). On a scale of 0-10, 10 being very difficult, the average participant expected level of difficulty with visualization was 6.89 and expected level of difficulty with instrumentation was 7.3. On postdissection assessment, there was a nonstatistically significant change to 6.93 and 7.5, respectively. Participants endorsed on a scale of 0-10, 10 being very realistic, an overall model realism of 7.0 and haptic realism of 7.1.

CONCLUSIONS

A 3D printed model of the pediatric skull base may provide a realistic model to help participants gain experience with anatomic limitations characteristic of the pediatric anterior skull base.