Repair of Frontal Skull Base Defects in Children: Should a Transnasal Approach Always Be Attempted First?

Objectives To describe a case of pediatric head trauma resulting in delayed cerebrospinal fluid (CSF) rhinorrhea due to a frontal/anterior skull base defect. To discuss the surgical decision making for endoscopic versus open treatment of such defects. To recognize the limitations of a totally endoscopic approach to repair of CSF leaks in this location. To review the literature of current treatment modalities for repair of adult versus pediatric skull base defects.

Methods Case presentation and review of literature.

Case Presentation A 4-year old girl sustained a skull base fracture after a fall from a second-floor balcony. She was noted at the time of injury to have a minimally depressed fracture involving the naso-orbito-ethmoid complex extending into the roof of a rudimentary frontal sinus. She was referred to our institution for persistent clear rhinorrhea 3 months after the injury and surgical repair was recommended. In an attempt to avoid craniotomy, the defect was repaired via a transnasal endoscopic approach with concurrent placement of a lumbar drain. The extreme anterior location of the defect made the repair challenging and a 70-degree endoscope and angled powered instrumentation were required. Ultimately, the closure appeared adequate and a craniotomy was not pursued. The patient returned 2 weeks postoperatively with recurrent CSF rhinorrhea, and a definitive repair was performed with a pericranial flap through a bicoronal approach.

Results We present a case of an extreme anterior skull base defect in a pediatric patient who ultimately underwent both transnasal endoscopic and open approaches to repair. Both procedures required similar operative times and similar postoperative length of stays. The transnasal approach often requires removal of nasal packing and compliance with a postoperative oral antibiotic and nasal saline regimen, which can be challenging in younger children. Open repair of an anterior defect requires minimal retraction of the frontal lobes and may be performed in an expeditious fashion with minimal “morbidity.”

Conclusion Despite advances in adult and pediatric endoscopic skull base surgery, the efficacy of transnasal endoscopic repair of glabellar defects in small children may be limited by a tight working space and extreme angle of approach required for repairing this area. Even when “minimally invasive” approaches are successful in this specific patient population, one can argue that the length of surgery and postoperative recovery for open and endoscopic approaches in small children may not differ significantly. If a transnasal endoscopic approach requires a longer duration of anesthesia, a longer course of postoperative antibiotics, packing removal, and compliance with a nasal hygiene regimen, a traditional open procedure may in fact impart less morbidity with a greater chance of success for extreme anterior skull base defects in small children.

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