How Low Can You Go? Comparing the Inferior Limit in Endoscopic Endonasal Approaches to the Craniovertebral Junction between Age Groups

Objectives: The transnasal approach has been demonstrated as an effective route for treating compressive disorders and other pathologies in the craniovertebral junction (CVJ). It is associated with fewer airway and swallowing complications and shorter hospital stays compared with the traditional transoral route. While the transnasal approach has gained acceptance in the adult population, this widespread acceptance has not been adopted in the pediatric population due to concern for theoretically limited inferior access. This study applies validated cephalometric tools to quantify and compare inferior access between pediatric and adult age groups.

Methods: Maxillofacial computed tomography scans of all patients who underwent functional endoscopic sinus surgery from January 2015 to May 2022 at a single tertiary care institution were obtained. Twenty-five scans from each age group (0–6, 6–13, 14–17, and 18+ at time of scan) were randomly selected for review. The spatial relationship between the nasopalatine, rhino palatine, and hard palate lines and key surgical landmarks in the craniovertebral junction were measured and reported ([Fig. 1]). Significance was determined using a Student's t-test and an α of < 0.05.

Results: The distance of the nasopalatine line to the inferior border of C1 in proportion to the height of C1 was significantly higher in the age less than 6 group (ratio: 1.05) compared with the adult group (ratio: 0.57; p = 0.01; [Fig. 2]). The average absolute distance between all subjects of the nasopalatine, rhino palatine, and hard palate lines below the inferior border of C1 were 7.56, –3.33, and ––10.76 mm, respectively. There were no significant differences between age groups for this measurement.

Conclusions: Contrary to the intuitive understanding, the inferior limit of endoscopic endonasal access to the CVJ is at least equal, and possibly improved, in pediatric compared with adult patients based on validated cephalometric tools. Since the endoscopic endonasal approach is associated with less morbidity than transoral or combined approaches, it should be considered to treat CVJ pathologies in patients of all ages.

Fig. 1 Demonstration of the nasopalatine (rhinion through hard palate posterior spine, red), rhino palatine (1/3 from anterior nasal spine to rhinion through hard palate posterior spine, blue), and hard palate (anterior nasal spine through hard palate posterior spine, green) lines. The distance between each of these lines and the inferior border of C1 and C2 were measured and compared for all patients included in the study.

Fig. 2 Bar graph demonstrating the distance of the nasopalatine line (blue) and rhino palatine line (orange) to the inferior border of C1 divided by the height of C1. This was significantly elevated in the age less than 6 group compared with the adult group (p = 0.01). There were no other significant differences between groups.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
01 February 2023