Expanded Endonasal Approaches for Skull Bases Lesions in the Very Young: Is It Safe and Effective?

Background The fully endoscopic expanded endonasal approach (EEA) has been shown to be safe and efficacious in pediatric patients. However, in the very young patient (≤ 6), the anatomical challenge of working through a small nasal corridor is problematic. The ability to repair the skull base and use a nasoseptal flap (NSF) has also been called into question. The objective of this study was to review skull base resections, patient age, tumor pathology, extent of resection, postoperative cerebrospinal fluid (CSF) leaks, and complications in patients aged 6 years and younger.

Methods A retrospective chart review was conducted on pediatric patients aged 6 years and younger who underwent EEA skull base resections over a 3-year period (June 2014 through June 2017).

Results: Eight children aged 6 years and younger (range = 1–6 years, mean = 4.3 years) underwent an EEA for resection of their skull base tumors, with a mean follow-up of 1.45 years. The tumor pathology included one craniopharyngioma (age 4 years), one Rathke cleft cyst (age 16 months), one encephalocele (age 6 years), one hamartoma (age 13 months), two chordomas (both age 6 years), one dermoid cyst (age 4 years), and one neuroblastoma (age 6 years).

A GTR was obtained in the craniopharyngioma, dermoid, neuroblastoma, and hamartoma cases. The chordoma cases were both addressed with multiple staged resections, and resulted in residual tumor adjacent to the carotid and brainstem that were addressed with postoperative proton therapy. The Rathke cleft cyst was opened and drained. The encephalocele was completely resected and paracribiform skull base repaired. There are no tumor recurrences to date.

A high-flow intraoperative CSF leak was encountered in the craniopharyngioma case, and both chordoma cases. All CSF leaks were repaired with NSFs that were able to reach and fully cover the defect. There were no postoperative CSF leaks. The patient with a craniopharyngioma suffered from postoperative hypopituitarism with TSH and ADH deficiencies. The patient with the hamartoma had recurrent epistaxis secondary to nasal dryness from turbinate destruction by the tumor. The neuroblastoma patient expired 8 months postresection secondary to metastatic disease. There were no orbital complications in any case.

Conclusion In the very young patient, age 6 years and less, the fully endoscopic EEAs for skull base tumors is a safe and effective surgical technique. Skull base defects are able to be effectively addressed with typical repairs including NSFs.