Open Approaches to the Anterior Skull Base in Children: Review of the Literature

Abstract

Skull base lesions in children and adolescents are rare, and comprise only 5.6% of all skull base surgery. Anterior skull base lesions dominate, averaging slightly more than 50% of the cases. Until recently, surgery of the anterior skull base was dominated by open procedures and endoscopic skull base surgery was reserved for benign pathologies. Endoscopic skull base surgery is gradually gaining popularity. In spite of that, open skull base surgery is still considered the "gold standard" for the treatment of anterior skull base lesions, and it is the preferred approach in selected cases. This article reviews current concepts and open approaches to the anterior skull base in children in the era of endoscopic surgery. Comprehensive literature review. Extensive intracranial-intradural invasion, extensive orbital invasion, encasement of the optic nerve or the internal carotid artery, lateral supraorbital dural involvement and involvement of the anterior table of the frontal sinus or lateral portion of the frontal sinus precludes endoscopic surgery, and mandates open skull base surgery. The open approaches which are used most frequently for surgical resection of anterior skull base tumors are the transfacial/transmaxillary, subcranial, and subfrontal approaches. Reconstruction of anterior skull base defects is discussed in a separate article in this supplement. Although endoscopic skull base surgery in children is gaining popularity in developed countries, in many cases open surgery is still required. In addition, in developing countries, which accounts for more than 80% of the world's population, limited access to expensive equipment precludes the use of endoscopic surgery. Several open surgical approaches are still employed to resect anterior skull base lesions in the pediatric population. With this large armamentarium of surgical approaches, tailoring the most suitable approach to a specific lesion in regard to its nature, location, and extent is of utmost importance.

Pediatric Anterior Skull Base Reconstruction With Bilateral Temporoparietal Fascial Flap

“…Approach of resection and reconstruction should be tailored to the size and structures involved. [20][21][22] The primary goals of ASB reconstruction include providing structural support for the cranial and orbital contents, obliterating dead space, providing a watertight dural seal, separation between cranial and sinonasal contents, and maintaining a functional sinonasal system. 1,5,16 Bony reconstruction has historically been debated in skull base reconstruction.…”

“…Approach of resection and reconstruction should be tailored to the size and structures involved. 20-22…”

Special Considerations in Pediatric Endoscopic Skull Base Surgery

“…While recent advancements in medical technology and surgical experience have greatly expanded the horizons of safe and effective minimally invasive approaches to the pediatric cranial base, traditional open approaches maintain a role in pediatric skull base surgery, although they are not specifically covered in this focused review [119]. Finally, this report was assembled to specifically address the perioperative care of patients undergoing solely endoscopic skull base surgery.…”