The Utility of A “Second Look” Debridement Following Endonasal Skull Base Surgery in the Pediatric Population

Objective: A sinonasal debridement is typically performed in the weeks following endonasal skull base surgery (ESBS) to clear the sinonasal cavity and to assess the status of the skull base. In the pediatric population, this may require a return to the operating room as younger patients are unable to tolerate endonasal instrumentation unless under general anesthesia. There is currently little evidence assessing the benefit of a second look procedure in pediatric patients, which may impose additional risks and costs.

Methods: This was a retrospective analysis of pediatric patients (age <18 years) that underwent a second look debridement under general anesthesia following ESBS at a tertiary care academic institution from 2010 to 2021. Intraoperative findings (crusting, scarring, infection, flap status) and interventions performed (lysis of adhesions, treatment of sinusitis, and revision of reconstruction) were recorded. Using the t-test, we assessed for significant differences in intraoperative findings for various patient and clinical factors, including initial age, diagnosis, revision, presence of cerebrospinal fluid (CSF) leak, and time between initial surgery and debridement.

Results: This study included 20 cases of second look debridements (age mean 8.0 ± 3.4 years, range 2–13 years), occurring a mean of 13.1 ± 7.9 days following ESBS. For the initial surgery, 50% (10/20) were performed for craniopharyngioma, 20% (4/20) were revision cases, and 85% (17/20) required reconstruction to repair a CSF leak. At debridement, crusting was noted in 70% (14/20) cases, scarring in 30% (6/20), sinusitis in 5% (1/20), and a nonviable reconstruction in 10% (2/20). Scarring was identified between the inferior turbinate and septum (n = 2), low middle turbinate and septum (n = 3), and within the olfactory cleft (n = 1), and in all cases scarring was divided at the time of debridement. Debridements that identified scarring were performed at a significantly later mean time (18.3 days), compared with debridements that did not identify scarring (10.7 days) (p = 0.04). Scarring did not occur at a significantly higher rate for younger age, revision cases or cases with nasoseptal flap harvest. There was no difference in incidence of crusting related to age, time to debridement, revisions, or nasoseptal flap harvest. At the time of debridement, two nasoseptal flaps were found to be nonviable with associated CSF leaks, prompting a subsequent revision reconstruction. In one case, purulence was identified emanating from the maxillary sinus, prompting a maxillary antrostomy and subsequent course of oral antibiotics. There were no perioperative complications noted for any second look debridement. Meaningful long-term outcome data was not able to be collected, as the majority of patients travelled to our institution from far distances for the initial surgery and then elected to receive follow-up care at their local institutions after the acute postoperative period.

Conclusion: Second look debridements allowed for early identification and intervention of sinonasal pathology or nonviable reconstructions in a considerable percentage of patients following pediatric ESBS, in a population that cannot always communicate symptoms. Larger, controlled studies would be useful to validate this practice and refine indications and timing of this second procedure.

Publication History

Article published online:
15 February 2022