Comprehensive Approach to Treatment of Pediatric Skull Base Lesions: A Case Series

Objective: The use of endoscopic or combined endoscopic and open approaches to pediatric skull base tumors and CSF leaks is a relatively recent advancement. An endoscopic approach, either alone or in conjunction with traditional craniotomy, can provide less disruptive and more efficacious treatment than craniotomy alone, especially in children. Additionally, current advances in endoscopic approaches have allowed for increased access through additional anatomical portals including transorbital neuroendoscopic surgery, paramaxillary, and other described pathways. The authors present their institutional experience with all noninflammatory skull base pathology, including trauma, treated endoscopically, or via combined endoscopic and open approach in a pediatric population.

Methods: The authors retrospectively reviewed pediatric patients (age ≤18 years) who had undergone treatment of skull base pathology via an endoscopic or combined endoscopic and open approach, including transorbital, between 2006 and 2019.

Results: This series included 57 unique patients who underwent 67 operations between the age of 1 and 18 years old (average age 12.1 years). Patients were treated for a variety of pathology including trauma/CSF leak (n = 27, 38.%), followed by skull base tumor, including juvenile angiofibroma and chordoma (n = 21, 29.6%), craniopharyngioma (n = 10, 14.1%), pituitary adenoma (n = 9, 12.7%), and encephalocele (n = 4, 5.6%). Of the cases that employed an endoscopic approach, 23 (34%) utilized a transorbital approach for access, whereas 57 (85%) used either an endonasal alone or an endonasal combined with nontransorbital approach. Nasoseptal flaps were used in 27% (n = 18) of cases, fat grafts in 13% (n = 9), and lumbar drains in 24% (n = 16). For patients with nontraumatic pathology, median length of hospital stay was 3 days (range, 1–43 days). Patients were followed for a median of 23 months (range, 0–1,091 months), with mean radiological follow-up of 18 months (range, 0–108 months). Postoperative CSF leak occurred in eight patients (14%). Favorable outcomes of surgery were sustained during the follow-up period with low rate of revision surgery (7%). Complication rate beyond CSF leaks was low with four patients (7%) suffering some other complication including bitemporal hemianopsia due to packing from leak closure impinging on the optic chiasm (n = 1), hardware infection (n = 1), and meningitis (n = 2).

Conclusion: In this single-institution report of endoscopic or combined endoscopic and open approach to pediatric skull base pathology, we demonstrate safety and effectiveness of treatment. Broad conclusions are challenging to make from this heterogeneous patient population. Of note, this is the first major review of pediatric transorbital series in the literature. Overall favorable effects of surgery were sustained during the follow-up period. Further refinement of technology and training will allow for more widespread use of these techniques in the pediatric population. Long-term craniofacial and radiologic outcomes are needed to further validate this method of approach.