Impact of skull base development on endonasal endoscopic surgical corridors

Banu, Matei; Guerrero-Maldonado, Amancio; McCrea, Heather J.; García-Navarro, Victor; Souweidane, Mark M.; Anand, Vijay K.; Heier, Linda; Schwartz, Theodore H.; Greenfield, Jeffrey P.

doi:10.3171/2013.10.peds13303

Cited by 52 publications

(50 citation statements)

References 22 publications

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“…5 The pneumatization process of the yet rudimental paranasal sinuses model skull base bone structures in a caudal-rostral pattern, while the sphenoid sinus pneumatization is a step-wise process following an anterior-posterior trend. 36 All these make the EEA a challenge to perform when dealing with pediatric craniopharyngiomas.…”

Section: Pediatric Eeamentioning

confidence: 99%

Suprasellar and recurrent pediatric craniopharyngiomas: expanding indications for the extended endoscopic transsphenoidal approach

Alalade¹,

Ogando‐Rivas²,

Boatey³

et al. 2018

Journal of Neurosurgery: Pediatrics

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OBJECTIVEThe expanded endonasal endoscopic transsphenoidal approach has become increasingly used for craniopharyngioma surgery in the pediatric population, but questions still persist regarding its utility in younger children, in recurrent and irradiated tumors, and in masses primarily located in the suprasellar region. The narrow corridor, incomplete pneumatization, and fear of hypothalamic injury have traditionally relegated this approach to application in older children with mostly cystic craniopharyngiomas centered in the sella. The authors present a series of consecutive pediatric patients in whom the endonasal endoscopic approach was used to remove craniopharyngiomas from patients of varied ages, regardless of the location of the tumor and previous treatments or surgeries, to ascertain if the traditional concerns about limitations of this approach are worth reevaluatingMETHODSEleven consecutive pediatric patients (age ≤ 18 years) underwent surgery via an endoscopic transsphenoidal approach at NewYork-Presbyterian/Weill Cornell Medical Center from 2007 to 2016. The authors recorded the location, consistency, and size of the lesion, assessed for hypothalamic invasion radiographically, calculated skull base measurements, and assessed parameters such as extent of resection, visual function, endocrinological function, weight gain, and return-to-school status.RESULTSThe average age at the time of surgery was 7.9 years (range 4–17 years) and the tumor sizes ranged from 1.3 to 41.7 cm3. Five cases were purely suprasellar, 5 had solid components, 4 were reoperations, and 5 had a conchal sphenoid aeration. Nevertheless, gross-total resection was achieved in 45% of the patients and 50% of those in whom it was the goal of surgery, without any correlation with the location, tumor consistency, or the age of the patient. Near-total resection, subtotal resection, or biopsy was performed intentionally in the remaining patients to avoid hypothalamic injury. Anterior pituitary dysfunction occurred in 81.8% of the patients, and 63.3% developed diabetes insipidus . Two patients (18%) had a greater than 9% increase in body mass index. Visual function was stable or improved in 73%. All children returned to an academic environment, with 10 of them in the grade appropriate for their age. There was a single case of each of the following: CSF leak, loss of vision unilaterally, and abscess.CONCLUSIONSThe endoscopic transsphenoidal approach is suitable for removing pediatric craniopharyngiomas even in young children with suprasellar tumors, conchal sphenoid sinus, recurrent tumors, and tumors with solid components. The extent of resection is dictated by intrinsic hypothalamic tumor invasiveness rather than the approach. The endoscopic transsphenoidal approach affords the ability to directly inspect the hypothalamus to determine invasion, which may help spare the patient from hypothalamic injury. Irrespective of approach, the rates of postoperative endocrinopathy remain high and the learning curve for the approach to a relatively rare tumor is steep.

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Section: Pediatric Eeamentioning

confidence: 99%

Suprasellar and recurrent pediatric craniopharyngiomas: expanding indications for the extended endoscopic transsphenoidal approach

Alalade¹,

Ogando‐Rivas²,

Boatey³

et al. 2018

Journal of Neurosurgery: Pediatrics

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“…Banu et al recently conducted a large retrospective series involving 107 pediatric patients and found that the nare-vomer distance varied significantly with respect to age, and the nare-sellar distance differed significantly with sex. 4 No differences, however, were noted in nasal restriction sites with respect to age, such as the width between middle turbinates or nasal aperture, suggesting access can be gained to pathology of the anterior craniocervical junction despite age and sex variance provided working angles and distances are favorable. Based on the results of this study, we surmise that the inferior extent of the EN approach is likely increased in individuals at the extremes of age (pediatrics and the elderly) relative to middle-aged individuals and similarly in females compared with males.…”

Section: Discussionmentioning

confidence: 99%

“…Banu and colleagues found both the working angle and distance of the EN corridor differed with age in a pediatric population. 4 As the C1-2 and hard palate relationship predicts the sagittal extent of exposure with EN approaches, we hypothesize that the relationship changes with age, similar to the working angle as described by Banu et al While this relationship likely also changes with respect to sex, as suggested by radiographic studies evaluating normal variance of markers for basilar invagination, 16,25 we also assessed and controlled for sex variation. The present study sought to characterize the anatomical relationship of C-2 and the hard palate with age and sex using sagittal CT.…”

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confidence: 99%

The rise and fall of the craniocervical junction relative to the hard palate: a lifetime story

Mallory

Arutyunyan²,

Murphy

et al. 2016

SPI

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OBJECT Endoscopic approaches to the anterior craniocervical junction are increasing in frequency. Choice of oral versus endoscopic endonasal approach to the odontoid often depends on the relationship of the C1–2 complex to the hard palate. However, it is not known how this relevant anatomy changes with age. We hypothesize that there is a dynamic relationship of C-2 and the hard palate, which changes with age, and potentially affects the choice of surgical approach. The aim of this study was to characterize the relationship of C-2 relative to the hard palate with respect to age and sex. METHODS Emergency department billing and trauma records from 2008 to 2014 were reviewed for patients of all ages who underwent cervical or maxillofacial CT as part of a trauma evaluation for closed head injury. Patients who had a CT scan that allowed adequate visualization of the hard palate, opisthion, and upper cervical spine (C-1 and C-2) were included. Patients who had cervical or displaced facial/skull base fractures, a history of rheumatoid arthritis, or craniofacial anomalies were excluded. The distance from McGregor's palatooccipital line to the midpoint of the inferior endplate of C-2 (McL–C2) was measured on midsagittal CT scans. Patients were grouped by decile of age and by sex. A 1-way ANOVA was performed with each respective grouping. RESULTS Ultimately, 483 patients (29% female) were included. The mean age was 46 ± 24 years. The majority of patients studied were in the 2nd through 8th decades of life (85%). Significant variation was found between McL–C2 and decile of age (p < 0.001) and sex (p < 0.001). The mean McL–C2 was 27 mm in the 1st decade of life compared with the population mean of 37 mm. The mean McL–C2 was also noted to be smaller in females (mean difference 4.8 mm, p < 0.0001). Both decile of age (p = 0.0009) and sex (p < 0.0001) were independently correlated with McL–C2 on multivariate analysis. CONCLUSIONS The relationship of C-2 and the hard palate significantly varies with respect to age and sex, descending relative to the hard palate a full centimeter on average in adulthood. These findings may have relevance in determining optimal surgical approaches for addressing pathology involving the anterior craniocervical junction.

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“…As the use of endoscopic endonasal techniques continues to advance, the pediatric population has benefited from the application of these techniques and technologies to manage their smaller and more complex anatomy. 4 Our study sought to define the costs of EES in the pediatric population to determine if it was a cost-effective model for the patient and the health care system. The average length of stay for our series was 4.5 days with 1.8 days in the ICU.…”

Section: Discussionmentioning

confidence: 99%