Transnasal endoscopic approach for pediatric skull base lesions: a case series

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OBJECTIVE

Transnasal endoscopic transsphenoidal approaches constitute an essential technique for the resection of skull base tumors in adults. However, in the pediatric population, sellar and suprasellar lesions have historically been treated by craniotomy. Transnasal endoscopic approaches are less invasive and thus may be preferable to craniotomy, especially in children. In this case series, the authors present their institutional experience with transnasal endoscopic transsphenoidal approaches for pediatric skull base tumors.

METHODS

The authors retrospectively reviewed pediatric patients (age ≤ 18 years) who had undergone transnasal endoscopic transsphenoidal approaches for either biopsy or resection of sellar or suprasellar lesions between 2007 and 2016. All operations were performed jointly by a team of pediatric neurosurgeons and skull base otolaryngologists, except for 8 cases performed by one neurosurgeon.

RESULTS

The series included 42 patients between 4 and 18 years old (average 12.5 years) who underwent 51 operations. Headache (45%), visual symptoms (69%), and symptoms related to hormonal abnormalities (71%) were the predominant presenting symptoms. Improvement in preoperative symptoms was seen in 92% of cases. Most patients had craniopharyngiomas (n = 16), followed by pituitary adenomas (n = 12), Rathke cleft cysts (n = 4), germinomas (n = 4), chordomas (n = 2), and other lesion subtypes (n = 4). Lesions ranged from 0.3 to 6.2 cm (median 2.5 cm) in their greatest dimension. Gross-total resection was primarily performed (63% of cases), with 5 subsequent recurrences. Nasoseptal flaps were used in 47% of cases, fat grafts in 37%, and lumbar drains in 47%. CSF space was entered intraoperatively in 15 cases, and postoperative CSF was observed only in lesions with suprasellar extension. There were 8 cases of new hormonal deficits and 3 cases of new cranial nerve deficits. Length of hospital stay ranged from 1 to 61 days (median 5 days). Patients were clinically followed up for a median of 46 months (range 1–120 months), accompanied by a median radiological follow-up period of 45 months (range 3.8–120 months). Most patients (76%) were offered adjuvant therapy.

CONCLUSIONS

In this single-institution report of the transnasal endoscopic transsphenoidal approach, the authors demonstrated that this technique is generally safe and effective for different types of pediatric skull base lesions. Favorable effects of surgery were sustained during a follow-up period of 4 years. Further refinement in technology will allow for more widespread use in the pediatric population.

ABBREVIATIONS GTR = gross-total resection; STR = subtotal resection.

Article Information

Correspondence Michael S. B. Edwards: Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, CA. edwards9@stanford.edu.

INCLUDE WHEN CITING Published online June 14, 2019; DOI: 10.3171/2019.4.PEDS18693.

Disclosures Dr. Hwang: consultant for Medtronic and Canon. Dr. Patel: consultant for Medtronic, Stryker, IntersectENT, and Optinose.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Preoperative coronal T2-weighted MR image showing the measurement of the cavernous intercarotid distance (line). Figure is available in color online only.

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    Bar graph showing the pathological subtypes of lesions among patients included in the study. Figure is available in color online only.

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    Scatterplot of age and cavernous intercarotid distance at the time of the first procedure. The red line represents a linear regression model showing the relationship between the two variables. Figure is available in color online only.

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    Pie chart showing the types of surgical procedures performed for patients included in the study. Figure is available in color online only.

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    Intraoperative endoscopic view demonstrating opening of the dura (A), tumor visualization (B), the optic nerve after tumor removal (C), and the third ventricle after tumor removal (D). Figure is available in color online only.

  • View in gallery

    Preoperative (A) and postoperative (B) postcontrast MR images obtained in an 11-year-old patient with a craniopharyngioma.

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