Pediatric Endoscopic Endonasal Skull Base Surgery: A Retrospective Review over the Past 11 Years

Introduction: Endonasal endoscopic approaches (EEAs) to the skull base were initially developed in the adult population and have been adapted for pediatric patients. There remains a paucity of data on outcomes of EEAs in a pediatric population. We summarize results of 11 years of pediatric skull base surgery in two tertiary referral hospitals.

Methods: A retrospective review of 97 patients undergoing 179 procedures between January 2007 and June 2018 at our respective institutions was conducted following IRB approval.

Results: A total of 179 skull base procedures were performed on 97 patients for resection of lesions or cerebrospinal fluid (CSF) leak following trauma or previous skull base intervention. In this population there were 45 females (46.4%) and 52 males (53.6%). Patients ranged from 9 months to 22 years of age, with an average age of 13 years (standard deviation: 4.4 years).

Of this population, 142 procedures had presenting symptoms documented. The most common symptoms prior to surgical intervention were vision changes (n = 34, 23.9%), headache (n = 22, 23.2%), disease progression on imaging (n = 27, 19%), and endocrine abnormalities (19, 13.3%). There were records regarding CSF leak for 141 patients. Overall, 16 cases had a postoperative CSF leak requiring intervention (11.3%) and 1 patient had a CSF leak that resolved without intervention (0.7%). Lumbar drains were placed in 40 cases intraoperatively or postoperatively (26.7% of 150 cases with records) and external ventricular devices were placed in 6 cases (4%). Intraoperative hemorrhage, defined as a blood loss over 400 cc, occurred in nine cases (6.4% of 141 cases with recorded estimated blood loss). Meningitis occurred following surgical interventions in 4 cases (2.8% of 144 procedures with records detailing presence or absence of meningitis). Finally, of 156 cases with postoperative endocrine testing, there were 18 instances of temporary or permanent diabetes insipidus (11.5%).

Skull base lesions were heterogeneous with 35 different pathologies. The most common lesions addressed were (1) craniopharyngioma (n = 17, 17.5%), (2) Rathke’s cleft cyst (n = 13, 13.4%), (3) chordoma (9, 9.2%), and (4) prolactinoma (5, 5.1%). Of the 97 patients, 28 had persistent disease (28.8%), 41 patients underwent adjuvant chemotherapy (42.2%), and 42 underwent adjuvant radiation therapy (43.2%).

Discussion: There are relatively few large retrospective reviews of outcomes following pediatric endoscopic skull base surgery. Our findings show a similar instance of postoperative CSF leak, meningitis, and diabetes insipidus when compared with research analyzing populations of equivalent size.[1] Our experience has shown that there are several skull base pathologies, especially chordomas and craniopharyngiomas, that are more likely to require repeat resections and have a higher propensity to CSF leak.

Conclusion: Retrospective review of endoscopic pediatric skull base surgery shows that it is a safe approach, in carefully selected patients, to address a wide variety of skull base pathology. Further research is needed to determine long-term outcomes of endoscopic skull base surgery in the pediatric population.

• Reference

• 1 Chivukula S, Koutourousiou M, Snyderman CH, Fernandez-Miranda JC, Gardner PA, Tyler-Kabara EC. Endoscopic endonasal skull base surgery in the pediatric population. J Neurosurg Pediatr 2013; 11 (03) 227-241