Endoscopic endonasal skull base surgery in the pediatric population

Chivukula, Srinivas; Koutourousiou, Maria; Snyderman, Carl H.; Fernández-Miranda, Juan C.; Gardner, Paul A.; Tyler-Kabara, Elizabeth C.

doi:10.3171/2012.10.peds12160

Cited by 126 publications

(152 citation statements)

References 72 publications

(117 reference statements)

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“…Feasibility of these approaches in children has been demonstrated. 4,8,9 However, successful EEA surgery requires an adequate working space for the endoscope as well as the instruments. Hesitations and questions have been raised regarding the feasibility of performing EEAs in pediatric patients, given the smaller working space compared with adults.…”

Section: 19mentioning

confidence: 99%

Impact of skull base development on endonasal endoscopic surgical corridors

Banu

Guerrero-Maldonado

McCrea

et al. 2014

PED

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Object Scarce morphometric data exist on the developing skull base as a corridor for endonasal endoscopic approaches (EEAs). Furthermore, the impact of skull base lesions on its development has not been assessed. The authors describe a novel set of anatomical parameters characterizing the developmental process as well as the utility of these parameters in preoperative planning and a feasibility assessment of EEAs for neurosurgical treatment of skull base lesions in children. Methods Based on specific MRI sequences in 107 pediatric patients (2–16 years of age) without skull base lesions (referred to here as the normal population), 3 sets of anatomical parameters were analyzed according to age group and sex: drilling distance, restriction sites, and working distance parameters. A separate set of patients undergoing EEAs was analyzed in similar fashion to address the impact of skull base lesions on the developmental process. Results The volume of the sphenoid sinus significantly increases with age, reaching 6866.4 mm3 in the 14–16 years age group, and directly correlates with the pneumatization type (r = 0.533, p = 0.0001). The pneumatization process progresses slowly in a temporal-posterior direction, as demonstrated by the growth trend of the sellar width (r = 0.428, p = 0.0001). Nasal restriction sites do not change significantly with age, with little impact on EEAs. The intercarotid distance is significantly different only in the extreme age groups (3.9 mm, p = 0.038), and has an important impact on the transsphenoidal angle and the intracranial dissection limits (r = 0.443, p < 0.0001). The 14.9° transsphenoidal angle at 2–4 years has a 37.6% significant increase in the 11–13 years age group (p = 0.001) and is highly dependent on pneumatization type. Age-dependent differences between working parameters are mostly noted for the extreme age groups, such as the 8.6-mm increase in nare-vomer distance (p = 0.025). The nare-sellar distance is the only parameter with significant differences based on sex. Skull base lesions induce a high degree of variance in skull base measurements, delaying development and decreasing parameter values. Skull base parameters are interdependent. Nare-sellar distance can be used to assess global skull base development because it highly correlates with the intercarotid distance in both the normal population and in patients harboring skull base lesions. Conclusions Skull base development is a slow, gradual, age-dependent, sex-independent process significantly altering endonasal endoscopic corridors. Preoperative MRI measurements of the pediatric skull base are thus a useful adjunct in choosing the appropriate corridor and in assessing working angles and limits during dissection or reparative surgery. Skull base lesions can significantly impact normal skull base development and age-dependent growth patterns.

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Section: 19mentioning

confidence: 99%

Impact of skull base development on endonasal endoscopic surgical corridors

Banu

Guerrero-Maldonado

McCrea

et al. 2014

PED

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“…Two patients (1.2%) developed a CSF leak, which is comparable to the 1.3% rate noted in other pediatric neurosurgery studies that have used PEG sealant (range 1.3%-17.5%). 4,6,11,14 Other studies examining CSF leak rate with PEG sealant were limited to adult cohorts but also reported a comparable leak rate. Boogaarts et al reported a 2.2% CSF leak rate in a nonrandomized, prospective trial; 2 Cosgrove et al, 1.8% in a prospective trial; 5 Weinstein et al, 7.6% in a retrospective review; 15 Than et al, 2% in a prospective review; 13 and Osbun et al, 0.8% in a prospective randomized trial.…”

Section: Discussionmentioning

confidence: 99%

“…[4][5][6][7][8]11,14 Although the safety of adjunctive closure techniques has been extensively studied in the adult population, few studies have evaluated the efficacy and/or safety of sealants in the pediatric population. …”

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confidence: 99%

Evaluation of complication rates of pediatric cranial procedures in which a polyethylene glycol sealant was used

Xiao-fang

Goodwin

Recinos

et al. 2014

PED

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Object Polyethylene glycol (PEG) sealant in conjunction with standard closure techniques is effective in preventing CSF leaks after cranial procedures in adult patients, but the safety of PEG sealant in the pediatric population has not been shown. Methods The authors performed a retrospective analysis of pediatric neurosurgery patients (0–18 years of age) treated from 2005 to 2010 at The Johns Hopkins Hospital. There were 163 patients who underwent cranial surgery with the use of PEG sealant as an adjunct to standard closure techniques. There were 92 males and 71 females with an average age of 10.2 years. The incidences of revision surgery, CSF leak, meningitis, and neurological deficit were recorded. Results In the cohort's 90-day postoperative clinical course, the authors found that 4 patients (2.5%) required revision surgery, 2 patients (1.2%) developed a CSF leak, 4 patients (2.5%) developed a superficial skin infection, and 1 patient developed meningitis (0.6%) with no deaths or neurological deficits observed. Conclusions PEG sealant appears to be a safe adjunct to standard dural closure in pediatric cranial surgery patients to augment dural closure.

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“…5,18,19,32,41 For properly selected tumors, EES offers several advantages over traditional methods, including the sparing of disfiguring facial incisions and craniotomy. EES allows the surgeons to access the entire ventral skull base, from the crista galli to the upper cervical spine, with minimal postoperative complications.…”

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confidence: 99%

Intraoperative neurophysiological monitoring during endoscopic endonasal surgery for pediatric skull base tumors

Elangovan¹,

Singh²,

Gardner³

et al. 2016

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OBJECT The aim of this study was to evaluate the value of intraoperative neurophysiological monitoring (IONM) using electromyography (EMG), brainstem auditory evoked potentials (BAEPs), and somatosensory evoked potentials (SSEPs) to predict and/or prevent postoperative neurological deficits in pediatric patients undergoing endoscopic endonasal surgery (EES) for skull base tumors. METHODS All consecutive pediatric patients with skull base tumors who underwent EES with at least 1 modality of IONM (BAEP, SSEP, and/or EMG) at our institution between 1999 and 2013 were retrospectively reviewed. Staged procedures and repeat procedures were identified and analyzed separately. To evaluate the diagnostic accuracy of significant free-run EMG activity, the prevalence of cranial nerve (CN) deficits and the sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 129 patients underwent 159 procedures; 6 patients had a total of 9 CN deficits. The incidences of CN deficits based on the total number of nerves monitored in the groups with and without significant free-run EMG activity were 9% and 1.5%, respectively. The incidences of CN deficits in the groups with 1 staged and more than 1 staged EES were 1.5% and 29%, respectively. The sensitivity, specificity, and negative predictive values (with 95% confidence intervals) of significant EMG to detect CN deficits in repeat procedures were 0.55 (0.22–0.84), 0.86 (0.79–0.9), and 0.97 (0.92–0.99), respectively. Two patients had significant changes in their BAEPs that were reversible with an increase in mean arterial pressure. CONCLUSIONS IONM can be applied effectively and reliably during EES in children. EMG monitoring is specific for detecting CN deficits and can be an effective guide for dissecting these procedures. Triggered EMG should be elicited intraoperatively to check the integrity of the CNs during and after tumor resection. Given the anatomical complexity of pediatric EES and the unique challenges encountered, multimodal IONM can be a valuable adjunct to these procedures.

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Endoscopic endonasal skull base surgery in the pediatric population

Cited by 126 publications

References 72 publications

Impact of skull base development on endonasal endoscopic surgical corridors

Impact of skull base development on endonasal endoscopic surgical corridors

Evaluation of complication rates of pediatric cranial procedures in which a polyethylene glycol sealant was used

Intraoperative neurophysiological monitoring during endoscopic endonasal surgery for pediatric skull base tumors

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