Endoscopic Endonasal Skull Base Surgery in Pediatric Patients. Review of the First Experience

Objective: To present initial experience of endoscopic endonasal skull base surgery in pediatric patients.

Methods: A short-term retrospective review of surgeries in pediatric patients performed in period between July 2015 and July 2016 was made. Patient’s age, type of pathology, reconstruction technique, complications and outcomes were collected. Two patients were operated in department of neurosurgery at Child Republican Clinical Hospital in Kazan-city and other four patients underwent surgery at Federal Center for Neurosurgery in Novosibirsk.

Results: A total six patients were operated and seven surgeries were performed. There were 5 males and one female. Patients age was between 6 month and 11 years with mean age of 4.5 years. There were 5 cases of CSF-leak and one case of craniopharyngioma. Three cases of CSF-leak were associated with head trauma and two patients had meningocele. Two patients with post-traumatic CSF-leak had a previous history of meningitis. One patient with meningocele had a nasal obstruction due to herniation mass and became leaking after wrong diagnostic suspecting a nasal cavity hematoma and puncture made by ENT-doctor at outpatient clinic. And 6-month old infant had a meningocele with CSF-leak as a part of comorbidity associated with prematurely on 37 weeks of gestation, bilateral choana atresia and interatrial septum defect. In post-traumatic cases a CSF-leak site was located at anterior skull-base at the level of ethmoid cells and cribriform plate. In patients with meningocele a CSF-leak site was at the anterior ethmoid cell in infant and fronto-nasal meningocele in another patient arise from the cribriform plate, both on the right side. All surgeries were purely endoscopic and were performed with usage of frameless image-guidance system through the unilateral or bi-nostril endoscopic endonasal approach (EEA). In this cases a reconstruction was performed in multilayer fashion - using artificial materials, free mucosal flap from middle turbinate, fat graft and fascia lata with fibrin glue. In case of a 7-year-old boy with craniopharyngioma a subtotal resection with multilayer reconstruction using facia lata, fat graft and pedicle vascularized naso-septal flap was performed. In all cases a CSF-diversion with external lumbar drain was utilized. Length of lumbar drainage staying was between 3 and 9 days with mean period of 5.8 days. A recurrent CSF-leak occurs in infant patient four weeks postoperatively and required a repeat reconstruction added with lumbar-peritoneal shunting. No complications associated with increasing of initial or appearance of new neurological deficit, so just as meningitis were noted. All patients were discharged from the hospitals in good condition.

Conclusion: Due to short period of follow-up we can say that EEA in pediatric patients well tolerated and could be successfully used in treatment of skull-base pathology. And the risk of recurrent CSF-leak in infants is much more higher.