Long-term impact of pediatric endoscopic endonasal skull base surgery on midface growth

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Cranial base development plays a large role in anterior and vertical maxillary growth through 7 years of age, and the effect of early endonasal cranial base surgery on midface growth is unknown. The authors present their experience with pediatric endoscopic endonasal surgery (EES) and long-term midface growth.


This is a retrospective review of cases where EES was performed from 2000 to 2016. Patients who underwent their first EES of the skull base before age 7 (prior to cranial suture fusion) and had a complete set of pre- and postoperative imaging studies (CT or MRI) with at least 1 year of follow-up were included. A radiologist performed measurements (sella-nasion [S-N] distance and angles between the sella, nasion, and the most concave points of the anterior maxilla [A point] or anterior mandibular synthesis [B point], the SNA, SNB, and ANB angles), which were compared to age- and sex-matched Bolton standards. A Z-score test was used; significance was set at p < 0.05.


The early surgery group had 11 patients, with an average follow-up of 5 years; the late surgery group had 33 patients. Most tumors were benign; 1 patient with a panclival arteriovenous malformation was a significant outlier for all measurements. Comparing the measurements obtained in the early surgery group to Bolton standard norms, the authors found no significant difference in postoperative SNA (p = 0.10), SNB (p = 0.14), or ANB (0.67) angles. The S-N distance was reduced both pre- and postoperatively (SD 1.5, p = 0.01 and p = 0.009). Sex had no significant effect. Compared to patients who had surgery after the age of 7 years, the early surgery group demonstrated no significant difference in pre- to postoperative changes with regard to S-N distance (p = 0.87), SNA angle (p = 0.89), or ANB angle (p = 0.14). Lesion type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group.


Though our cohort of patients with skull base lesions demonstrated some abnormal measurements in the maxillary-mandibular relationship before their operation, their postoperative cephalometrics fell within the normal range and showed no significant difference from those of patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

ABBREVIATIONS A point = most concave point of anterior maxilla; AVM = arteriovenous malformation; B point = most concave point on anterior mandibular symphysis; EES = endoscopic endonasal surgery; GH = growth hormone; N = nasion; S = sella; UPMC = University of Pittsburgh Medical Center.

Article Information

Correspondence Paul A. Gardner: UPMC Center for Cranial Base Surgery, Pittsburgh, PA. gardpa@upmc.edu.

INCLUDE WHEN CITING Published online January 11, 2019; DOI: 10.3171/2018.8.PEDS18183.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Cephalometric measurements. These points and composite angles describe the position of the maxilla and mandible within the craniofacial skeleton, and in relation to each other. The nasion is the juncture of the frontal bone and the nasal bones; the A point is the most concave aspect of the maxilla; and the B point is the most concave aspect of the mandible. Figure is available in color online only.

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    Representative sagittal preoperative MR image (left) and axial postoperative CT image (right) obtained in a typical patient from the early surgery group. Compared to standard normative growth measurements, no significant midface differences were noted postoperatively.





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