Predicting the limits of the endoscopic endonasal approach in children: a radiological anatomical study

Youssef, Carl; Smotherman, Carmen; Kraemer, Dale F.; Aldana, Philipp R.

doi:10.3171/2015.6.peds14695

Cited by 16 publications

(18 citation statements)

References 26 publications

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“…29 Wider intercarotid distance and shorter nare-dens working distance are associated with better resection outcomes. 4,39 In our study, the cavernous intercarotid distance of the overall study cohort, whose mean age was in the early teens, was comparable to the length reported in adults. 26 The lack of significant difference in cavernous intercarotid distance between adults and children older than 9 years has been previously reported.…”

Section: Anatomical Limitationssupporting

confidence: 72%

Transnasal endoscopic approach for pediatric skull base lesions: a case series

Quon¹,

Kim²,

Hwang

et al. 2019

Journal of Neurosurgery: Pediatrics

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OBJECTIVETransnasal endoscopic transsphenoidal approaches constitute an essential technique for the resection of skull base tumors in adults. However, in the pediatric population, sellar and suprasellar lesions have historically been treated by craniotomy. Transnasal endoscopic approaches are less invasive and thus may be preferable to craniotomy, especially in children. In this case series, the authors present their institutional experience with transnasal endoscopic transsphenoidal approaches for pediatric skull base tumors.METHODSThe authors retrospectively reviewed pediatric patients (age ≤ 18 years) who had undergone transnasal endoscopic transsphenoidal approaches for either biopsy or resection of sellar or suprasellar lesions between 2007 and 2016. All operations were performed jointly by a team of pediatric neurosurgeons and skull base otolaryngologists, except for 8 cases performed by one neurosurgeon.RESULTSThe series included 42 patients between 4 and 18 years old (average 12.5 years) who underwent 51 operations. Headache (45%), visual symptoms (69%), and symptoms related to hormonal abnormalities (71%) were the predominant presenting symptoms. Improvement in preoperative symptoms was seen in 92% of cases. Most patients had craniopharyngiomas (n = 16), followed by pituitary adenomas (n = 12), Rathke cleft cysts (n = 4), germinomas (n = 4), chordomas (n = 2), and other lesion subtypes (n = 4). Lesions ranged from 0.3 to 6.2 cm (median 2.5 cm) in their greatest dimension. Gross-total resection was primarily performed (63% of cases), with 5 subsequent recurrences. Nasoseptal flaps were used in 47% of cases, fat grafts in 37%, and lumbar drains in 47%. CSF space was entered intraoperatively in 15 cases, and postoperative CSF was observed only in lesions with suprasellar extension. There were 8 cases of new hormonal deficits and 3 cases of new cranial nerve deficits. Length of hospital stay ranged from 1 to 61 days (median 5 days). Patients were clinically followed up for a median of 46 months (range 1–120 months), accompanied by a median radiological follow-up period of 45 months (range 3.8–120 months). Most patients (76%) were offered adjuvant therapy.CONCLUSIONSIn this single-institution report of the transnasal endoscopic transsphenoidal approach, the authors demonstrated that this technique is generally safe and effective for different types of pediatric skull base lesions. Favorable effects of surgery were sustained during a follow-up period of 4 years. Further refinement in technology will allow for more widespread use in the pediatric population.

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Section: Anatomical Limitationssupporting

confidence: 72%

Transnasal endoscopic approach for pediatric skull base lesions: a case series

Quon¹,

Kim²,

Hwang

et al. 2019

Journal of Neurosurgery: Pediatrics

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“…Prior radioanatomic studies revealed no statistically significant increase in piriform aperture diameter from that of the neonate until 15 to 18 years, but the clinical significance of these small changes is notable. While the authors report clinically meaningful increases in piriform distance at 10 years of age, we would propose that the clinical ease of access undergoes clinically significant increased size between 2 and 6 years. With small changes in diameter from 15 to 20 mm, the cross‐sectional area nearly doubles, affording four‐handed instrumentation with greater ease and in the experience of the authors, a piriform diameter greater than 2 cm affords unrestricted access for four‐handed surgery.…”

Section: Introductionmentioning

confidence: 85%

“…The published norms for piriform aperture width at birth, 2 years, and 5 years reveal increasing diameter from 15 to 18 mm to greater than 20 mm, respectively . Prior radioanatomic studies revealed no statistically significant increase in piriform aperture diameter from that of the neonate until 15 to 18 years, but the clinical significance of these small changes is notable. While the authors report clinically meaningful increases in piriform distance at 10 years of age, we would propose that the clinical ease of access undergoes clinically significant increased size between 2 and 6 years.…”

Section: Introductionmentioning

confidence: 88%

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

London

Rangel

Walz

2020

Laryngoscope Investig Oto

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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: 3aK E Y W O R D S endoscopic endonasal approach, pediatric skull base surgery, skull base reconstruction, surgical outcomes

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“…The following approaches are currently applied for surgical extirpation of anterior skull base tumors in children: (1) subfrontal, (2) subcranial, (3) transfacial/transmaxillary, (4) combined subcranial-transfacial approach, (5) combined subcranial-midfacial degloving, and (6) combined subcranialtransorbital. 1,3,4,[8][9][10][11][12][13][14] The approaches which are used most widely for surgical resection of anterior skull base tumors are the transfacial/ transmaxillary, subcranial, and subfrontal approaches. [3][4][5] Bilateral/Unilateral Subfrontal Approach This approach is primarily used for tumors of the anterior skull base with intracranial involvement.…”

Section: Open Approaches To the Anterior Skull Base In Childrenmentioning

confidence: 99%

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

et al. 2018

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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.

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Predicting the limits of the endoscopic endonasal approach in children: a radiological anatomical study

Cited by 16 publications

References 26 publications

Transnasal endoscopic approach for pediatric skull base lesions: a case series

Transnasal endoscopic approach for pediatric skull base lesions: a case series

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

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

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