Approaching the Sella through the Nonpneumatized Sphenoid in Pediatric Patients

Abstract

Objective The purpose of this study is to specifically assess pediatric patients with nonpneumatized sphenoid sinuses who have undergone transsphenoidal resections of skull base tumors and assess the complications and outcomes.

Methods Data was collected by a retrospective chart review done on children ages 7 and under who underwent endoscopic tumor resection and had a partially or completely nonpneumatized sphenoid sinus on preoperative computed tomography imaging. Surgical data collected included surgical corridor, gross total versus subtotal resection, repair method, use of septal flap, intraoperative and postoperative cerebrospinal fluid leak, and estimated blood loss.

Results Six patients were identified that fit our inclusion criteria who underwent surgery between November 2015 and April 2018 (3 males, 3 females; average age = 4.28 years). Tumor pathologies include three craniopharyngiomas, Rathke cleft cyst, meningocele, and neuroblastoma. All cases involved varying percentages of sphenoid sinus pneumatization. All cases except one craniopharyngioma and the neuroblastoma required removal of cancellous bone to access pathology. Degree of sphenoid pneumatization tended to be greater with age and resulted in less intraoperative bleeding. The two youngest patients with completely nonpneumatized sphenoid sinuses lost 61.73 and 17.52% of their total blood volume intraoperatively. Procedures were able to be adequately performed and pathology completely addressed with minimal postoperative complications and no postoperative CSF leaks.

Conclusions Intraoperative challenges including hemorrhage are likely in nonpneumatized patients, and thus surgeons should be prepared with adequate vascular access and blood products. Hemorrhage and total blood volume loss are increased in the younger patients with no sphenoid pneumatization. Despite the additional challenges, a nonpneumatized sphenoid sinus is not a contraindication for an endoscopic resection in the pediatric population.

Keywords

transsphendoidal resection - nonpneumatized sphenoid sinus - skull base tumor - endoscopic tumor resection

Note

This manuscript has been accepted for podium presentation at the 2018 North American Skull Base Society Conference in Orlando.

Financial Disclosures

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

• References

• 1 Alalade AF, Ogando-Rivas E, Boatey J. , et al. Suprasellar and recurrent pediatric craniopharyngiomas: expanding indications for the extended endoscopic transsphenoidal approach. J Neurosurg Pediatr 2018; 21 (01) 72-80
• 2 Elhamshary AS, Romeh HE, Abdel-Aziz MF, Ragab SM. Endoscopic approaches to benign sphenoid sinus lesions: development of an algorithm based on 13 years of experience. J Laryngol Otol 2014; 128 (09) 791-796
• 3 Tajudeen BA, Kennedy DW. Thirty years of endoscopic sinus surgery: what have we learned?. World J Otorhinolaryngol Head Neck Surg 2017; 3 (02) 115-121
• 4 Weber RK. [Comprehensive review on endonasal endoscopic sinus surgery]. Laryngorhinootologie 2015; 94 (Suppl. 01) S64-S142
• 5 Brockmeyer D, Gruber DP, Haller J, Shelton C, Walker ML. Pediatric skull base surgery. 2. Experience and outcomes in 55 patients. Pediatr Neurosurg 2003; 38 (01) 9-15
• 6 Song Y, Wang T, Chen J, Tan G. Endoscopic transsphenoidal resection of sellar tumors with conchal sphenoid sinus: a report of two cases. Oncol Lett 2015; 9 (02) 713-716
• 7 Nation J, Schupper AJ, Deconde A, Levy M. Pediatric endoscopic endonasal approaches for skull base lesions in the very young: is it safe and effective?. J Neurol Surg B Skull Base 2018; 79 (06) 574-579
• 8 Vaezi A, Cardenas E, Pinheiro-Neto C. , et al. Classification of sphenoid sinus pneumatization: relevance for endoscopic skull base surgery. Laryngoscope 2015; 125 (03) 577-581
• 9 Gruber DP, Brockmeyer D. Pediatric skull base surgery. 1. Embryology and developmental anatomy. Pediatr Neurosurg 2003; 38 (01) 2-8
• 10 Kim YH, Wang KC, Phi JH, Kim SK. Endoscopic endonasal approach for suprasellar lesions in children: complications and prevention. J Korean Neurosurg Soc 2017; 60 (03) 315-321
• 11 Morgan EGMM, Murray MJ. Clinical Anesthesiology. Third Edition. New York, NY: Lange Medical Books/McGraw Hill Medical Pub. Division; 2006
• 12 Hamid O, El Fiky L, Hassan O, Kotb A, El Fiky S. Anatomic variations of the sphenoid sinus and their impact on trans-sphenoid pituitary surgery. Skull Base 2008; 18 (01) 9-15
• 13 Citardi MJ, Gallivan RP, Batra PS. , et al. Quantitative computer-aided computed tomography analysis of sphenoid sinus anatomical relationships. Am J Rhinol 2004; 18 (03) 173-178
• 14 Magro F, Solari D, Cavallo LM. , et al. The endoscopic endonasal approach to the lateral recess of the sphenoid sinus via the pterygopalatine fossa: comparison of endoscopic and radiological landmarks. Neurosurgery 2006; 59 (04) (Suppl. 02) ONS237-ONS242 , discussion ONS242–ONS243
• 15 Rhoton Jr AL. The sellar region. Neurosurgery 2002; 51 (4, Suppl): S335-S374
• 16 Kikuchi R, Toda M, Tomita T, Ogawa K, Yoshida K. Analysis of sphenoid sinus lateral pneumatization for endonasal endoscopic surgery. Surg Neurol Int 2015; 6: 166