Special Considerations in Pediatric Neurotologic Skull Base Surgery

Outcome Objectives: Identify pediatric-specific considerations in neurotologic skull base surgery. Describe collaborative strategies in pediatric skull base surgery.

Methods: In a retrospective chart review of a tertiary-care, Neurotology skull base surgery program, 247 consecutive skull base surgeries from 2011 to 2015 included seven pediatric patients with: recurrent endolymphatic sac tumor, acoustic neuroma, Langerhans cell histiocytosis, brainstem astrocytoma, recurrent Hyrtle’s fissure, glioependymal cyst, and NF-2. The specific diagnoses, length of stay, return to pre-surgical activity and perioperative features distinguishing these pediatric procedures from adult procedures are the focus of this review.

Results: Case 1 (AN) illustrates the necessity of CPA imaging in pediatric asymmetric SNHL. Case 2 (Astro) illustrates the value of ABR, despite normal routine audiometry in pediatric skull base planning and surgical approach selection. Case 3 (EST) illustrates complex, multi-institutional comprehensive management of total temporal bone resection with carotid resection. Case 4 (Hist) illustrates successful oncological and vestibular management despite tumor invasion of the otic capsule. Case 5 (NF2) demonstrates tumor techniques to prolong sports participation in a teenager with multiple intracranial and spinal lesions. Case 6 (glioependymal cyst) demonstrates the necessity of CPA imaging in a patient with facial paresis, asymmetric SNHL, and the surgical management of a rare clinical lesion. Case 7 (Hyrt) illustrates the role of posterior fossa endoscopic techniques to avoid otic capsule removal in a recurrent congenital CSF fistula.

Conclusion: While the prevalence of diagnoses in these pediatric patients are different from the adult skull base patients, these children demonstrated remarkable resilience with uniform return to pre-surgical activity levels. Pediatric neurotologic skull base surgery has distinct diagnostic, surgical planning, anesthesia, intraoperative decision making, postoperative management, interdisciplinary and inter-institutional collaboration considerations.