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Valencia-Sanchez BA, Kim JD, Zhou S, Chen S, Levy ML, Roxbury C, Patel VA, Polster SP. Special Considerations in Pediatric Endoscopic Skull Base Surgery. J Clin Med 2024; 13:1924. [PMID: 38610689 PMCID: PMC11013018 DOI: 10.3390/jcm13071924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.
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Affiliation(s)
| | - Jeeho D. Kim
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Sheng Zhou
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Los Angeles, CA 90033, USA
| | - Sonja Chen
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
| | - Michael L. Levy
- Division of Pediatric Neurosurgery, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Neurosurgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology, University of Chicago Medicine, Chicago, IL 60637, USA;
| | - Vijay A. Patel
- Division of Pediatric Otolaryngology, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Sean P. Polster
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
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Miranda-Lloret P, Simal-Julian JA, de San Román-Mena LP, Ramírez EP, Pancucci G, Asunción CB. CSF leak after pediatric endoscopic endonasal expanded approaches: a series review. Childs Nerv Syst 2024; 40:181-188. [PMID: 37561159 DOI: 10.1007/s00381-023-06103-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/23/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE Endoscopic endonasal approaches in the pediatric population pose specific challenges. Management of postoperative cerebrospinal fluid [CSF] leak is probably the major concern. The purpose of the present investigation is to describe and analyze the incidence of postoperative CSF leaks in our pediatric series of endoscopic endonasal approaches. METHODS This is a retrospective analysis, case review of our institutional series. Descriptive statistical parameters and bivariate correlations are analyzed. RESULTS Twenty-one patients have been operated through endoscopic approaches in our series. Four patients showed a postoperative CSF leak needing a revision surgery; these cases are described in further detail. Approaches expanded beyond the sellar area and non-sellar pneumatization of the sphenoid sinus were significantly associated with a higher risk of postoperative CSF leak. CONCLUSIONS CSF leak incidence after endoscopic endonasal approaches is higher in pediatric patients than in adult series. Anatomic and pathologic factors add complexity to these approaches in children. Multilayer closure is advisable to prevent and treat this complication.
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Affiliation(s)
- Pablo Miranda-Lloret
- Pediatric Neurosurgery, Hospital Universitari I Politècnica La Fe, 46010, Valencia, Spain.
| | | | | | - Estela Plaza Ramírez
- Pediatric Neurosurgery, Hospital Universitari I Politècnica La Fe, 46010, Valencia, Spain
| | - Giovanni Pancucci
- Pediatric Neurosurgery, Hospital Universitari I Politècnica La Fe, 46010, Valencia, Spain
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AlKandery M, AlSaidan L, Owayed F, AlQunaee M, Al-Sihan M, Alterki A. Management of a pediatric patient with spontaneous cerebrospinal fluid leak in the lateral recess of sphenoid sinus and meningoencephalocele: A case report and literature review. Int J Surg Case Rep 2023; 110:108727. [PMID: 37659158 PMCID: PMC10509913 DOI: 10.1016/j.ijscr.2023.108727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 09/04/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Spontaneous cerebrospinal fluid (CSF) leak in the lateral recess of the sphenoid (LRS) sinus in a pediatric population is rare and is surgically challenging to repair. CASE PRESENTATION We report a case of a 13-year-old girl with hydrocephalus and a ventriculoperitoneal shunt who presented with a two-month history of clear rhinorrhea from the right nostril. Computed tomography (CT) of the head was performed and showed CSF leak through a defect in the lateral recess of the sphenoid sinus. Defect closure was achieved using an endoscopic endonasal approach. CLINICAL DISCUSSION CSF leak with meningoencephalocele from the sphenoid sinus is amongst the most difficult cases for repair. Yet the successful rate of repair is as high as 90 % if done endoscopically. Moreover, the location of the defect determines the surgical approach. CONCLUSION Spontaneous CSF rhinorrhea from the lateral recess of the sphenoid (LRS) sinus, although rare, requires prompt diagnosis and treatment, as it may lead to significant mortality and morbidity.
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Affiliation(s)
- Mashael AlKandery
- Department of Otolaryngology, Head and Neck Surgery, Zain Hospital, Kuwait
| | - Lulwah AlSaidan
- Department of Otolaryngology, Head and Neck Surgery, Zain Hospital, Shuwaikh Medical Area, Kuwait.
| | - Farhan Owayed
- Department of Otolaryngology, Head and Neck Surgery, Zain Hospital, Shuwaikh Medical Area, Kuwait
| | - Marwan AlQunaee
- Department of Otolaryngology, Head and Neck Surgery, Zain Hospital, Shuwaikh Medical Area, Kuwait
| | - Mutlaq Al-Sihan
- Department of Otolaryngology, Head and Neck Surgery, Zain Hospital, Shuwaikh Medical Area, Kuwait
| | - Abdulmohsen Alterki
- Department of Otolaryngology, Head and Neck Surgery, Zain Hospital, Shuwaikh Medical Area, Kuwait
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Wang R, Zhou G, Wang J, Ma B, Wang P, Gao G, Sun S, Zhang Z. Reducing CSF complications by a recycled Hadad's flap combined with autologous mucosa in secondary endoscope transsphenoidal surgery. Front Oncol 2023; 13:1224804. [PMID: 37601654 PMCID: PMC10433748 DOI: 10.3389/fonc.2023.1224804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Background Transsphenoidal secondary operations are a minority but not a rare occurrence. How to viably prevent cerebral fluid (CSF)-related complications and confine surgery-caused injury in secondary surgery as minimally as possible is a huge challenge. This article shares our solution of recycling a prior Hadad-Bassagasteguy flap (HBF) along with a using small piece of free autologous mucosa to reconstruct the skull base. Methods Of 69 patients, fitted criteria were assigned into 2 different groups: a recycled HBF incorporated with an autologous free mucosa and a recycled HBF incorporated with an artificial dura to rebuild the skull base in secondary transsphenoidal surgery. The postoperative morbidities of pseudomeningocele, CSF leakage and meningitis were recorded and analyzed. Results A recycled HBF incorporated with an autologous mucosa is capable of reducing CSF complications compared to that of the matched group, particularly decreasing the morbidity of meningitis in secondary transsphenoidal surgery. Diabetes mellitus, craniopharyngioma, chordoma and the utilization of artificial dura were independent risk factors for CSF complications in secondary transsphenoidal surgery through univariate and multivariate logistic regression. In addition, diabetes mellitus and artificial dura are more likely to induce CSF leakage and meningitis. Patients suffering from craniopharyngioma are more susceptible to meningitis. Chordoma indiscriminately increased the risk of each CSF complication. Conclusion A recycled HBF incorporated with an autologous mucosa is reliable for reconstructing the skull base in secondary transsphenoidal surgery, especially for patients simultaneously suffering from diabetes mellitus and central skull base tumors.
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Affiliation(s)
| | | | | | | | | | | | | | - Zhiguo Zhang
- Department of Neurosurgery, Tangdu Hospital, The Air Force Military Medical University, Xi’an, Shaanxi, China
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Pang JC, Chung DD, Wang J, Abiri A, Lien BV, Himstead AS, Ovakimyan A, Kim MG, Hsu FPK, Kuan EC. Characteristics and Outcomes in Pediatric Versus Adult Craniopharyngiomas: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 92:1112-1129. [PMID: 36639856 DOI: 10.1227/neu.0000000000002346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/05/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Craniopharyngiomas account for 1.2% to 4.6% of all intracranial tumors. Although age at presentation is distributed bimodally, with a pediatric peak occurring between 5 and 15 years and an adult peak between 50 and 70 years, presentation, treatment, and outcome differences between these two craniopharyngioma populations have not been thoroughly characterized. OBJECTIVE To compare treatments and outcomes between adult and pediatric craniopharyngiomas. METHODS This is a systematic review and meta-analysis. Web of Science, MEDLINE, and Scopus databases were searched for primary studies reporting postoperative complications, functional outcomes, recurrence, and overall survival in patients with craniopharyngioma undergoing surgery. RESULTS The search yielded 1,202 unique articles, of which 106 (n=4,202 patients) met criteria for qualitative synthesis and 23 (n=735 patients) met criteria for meta-analysis. Compared with adult, pediatric craniopharyngiomas were less likely to present with visual defects (odds ratio [OR] 0.54, 95% CI 0.36-0.80) or cognitive impairment (OR 0.29, 95% CI 0.12-0.71) and more likely with headaches (OR 2.08, 95% CI 1.16-3.73). Children presented with significantly larger tumors compared with adults (standardized mean difference 0.68, 95% CI 0.38-0.97). Comparing functional outcomes, pediatric patients sustained higher rates of permanent diabetes insipidus (OR 1.70, 95% CI 1.13-2.56), obesity (OR 3.15, 95% CI 1.19-8.31), and cranial nerve and/or neurological defects (OR 4.87, 95% CI 1.78-13.31) than adults. No significant differences were found in rates of postoperative cerebrospinal fluid leak, overall or progression-free survival, or recurrence. CONCLUSION Adult and pediatric craniopharyngiomas seem to have fundamental differences in clinical presentation and functional outcomes. These patients frequently require multimodality treatment and are best managed with a multidisciplinary team and an individualized approach.
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Affiliation(s)
- Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Dean D Chung
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Jenny Wang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Andrew Ovakimyan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Michael G Kim
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
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Hara T, Akutsu H, Tanaka S, Kino H, Miyamoto H, Ii R, Takano S, Ishikawa E. Risk Factors for Postoperative Cerebrospinal Fluid Leak after Graded Multilayer Cranial Base Repair with Suturing via the Endoscopic Endonasal Approach. Neurol Med Chir (Tokyo) 2023; 63:48-57. [PMID: 36436977 PMCID: PMC9995146 DOI: 10.2176/jns-nmc.2022-0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study analyzed risk factors for postoperative cerebrospinal fluid (CSF) leak after graded multilayer cranial base repair method with dural suturing. We performed surgery via the endoscopic endonasal approach (EEA) from 2012.6 to 2018.4, and those consecutive clinical data were prospectively accumulated and retrospectively analyzed. We tailored the repair method according to the intraoperative CSF leak grade. Among 388 surgeries via the EEA, there were 10 (2.6%) cases of postoperative CSF leak after graded repair with suturing. Postoperative CSF leak occurred in two of the 150 cases without intraoperative CSF leak (grade 0), one of the 104 cases with small (grade 1) intraoperative CSF leak, two of the 60 cases with moderate (grade 2) leak, and five of the 74 cases with large (grade 3) leak. Univariate analysis indicated that chordoma (P = 0.023), estimated tumor volume ≥ 7400 mm3 (P = 0.003), and maximum tumor diameter ≥ 32.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Additionally, among cases with intraoperative grade 3 CSF leak, chordoma (P = 0.021), estimated tumor volume ≥ 23000 mm3 (P = 0.003), and maximum tumor diameter ≥ 45.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Maximum tumor diameter, estimated tumor volume, and chordoma tumor pathology are related to a higher risk of postoperative CSF leak.
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Affiliation(s)
- Takuma Hara
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba.,Department of Neurosurgery, Tsukuba Medical Center Hospital
| | - Hiroyoshi Akutsu
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba.,Department of Neurosurgery, Dokkyo Medical University
| | - Shuho Tanaka
- Department of Otolaryngology, Faculty of Medicine, University of Tsukuba
| | - Hiroyoshi Kino
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Hidetaka Miyamoto
- Department of Otolaryngology, Faculty of Medicine, University of Tsukuba
| | - Rieko Ii
- Department of Otolaryngology, Faculty of Medicine, University of Tsukuba
| | - Shingo Takano
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
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Neurosurgical Treatment and Outcome of Pediatric Skull Base Lesions: A Case Series and Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020216. [PMID: 36832345 PMCID: PMC9954611 DOI: 10.3390/children10020216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Pediatric skull base lesions occur rarely and are of various etiologies. Traditionally, open craniotomy has been the treatment of choice; however, nowadays, endoscopic approaches are increasingly applied. In this retrospective case series, we describe our experience in treating pediatric skull base lesions and provide a systematic overview of the literature on the treatment and outcome of pediatric skull base lesions. METHODS We conducted a retrospective data collection of all pediatric patients (<18 years) treated for a skull base lesion at the Division of Pediatric Neurosurgery, University Children's Hospital Basel, Switzerland, between 2015 and 2021. Descriptive statistics and a systematic review of the available literature were additionally conducted. RESULTS We included 17 patients with a mean age of 8.92 (±5.76) years and nine males (52.9%). The most common entity was sellar pathologies (n = 8 47.1%), with craniopharyngioma being the most common pathology (n = 4, 23.5%). Endoscopic approaches, either endonasal transsphenoidal or transventricular, were used in nine (52.9%) cases. Six patients (35.3%) suffered from transient postoperative complications, while in none of the patients these were permanent. Of the nine (52.9%) patients with preoperative deficits, two (11.8%) showed complete recovery and one (5.9%) partial recovery after surgery. After screening 363 articles, we included 16 studies with a total of 807 patients for the systematic review. The most common pathology reported in the literature confirmed our finding of craniopharyngioma (n = 142, 18.0%). The mean PFS amongst all the studies included was 37.73 (95% CI [36.2, 39.2]) months, and the overall weighted complication rate was 40% (95% CI [0.28 to 0.53] with a permanent complication rate of 15% (95% CI [0.08 to 0.27]. Only one study reported an overall survival of their cohort of 68% at five years. CONCLUSION This study highlights the rarity and heterogeneity of skull base lesions in the pediatric population. While these pathologies are often benign, achieving GTR is challenging due to the deep localization of the lesions and eloquent adjacent structures, leading to high complication rates. Therefore, skull base lesions in children require an experienced multidisciplinary team to provide optimal care.
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Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci 2022; 12:brainsci12121685. [PMID: 36552145 PMCID: PMC9776068 DOI: 10.3390/brainsci12121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care.
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Yang X, Tang L, Wang P, Ge M, Zhang W, Xiao X, Han Y, Ge W. Bath‐plug technique for the endoscopic management of cerebrospinal fluid leaks in children. Pediatr Investig 2022; 7:23-28. [PMID: 36967735 PMCID: PMC10030683 DOI: 10.1002/ped4.12354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 10/25/2022] [Indexed: 11/24/2022] Open
Abstract
Importance The safety and efficacy of the bath-plug technique for the closure of cerebrospinal fluid (CSF) leaks in children remain unknown. Objective We undertook this study to ascertain whether the bath-plug technique was safe and effective for the repair of CSF leaks. Methods We retrospectively reviewed patients who underwent endoscopic repair of CSF leaks with the fat graft as a plug-in at Beijing Children's Hospital from March 2016 to May 2020. Demographic data, medical history, defect sites and sizes, interventions, and clinical outcomes were analyzed. One representative clinical case was additionally selected to highlight the procedure and the healing process. Results A total of 18 pediatric patients were included in this study. The group was composed of 11 boys and seven girls, aged from 5 to 123 months. The etiologies included congenital CSF leaks (n = 9) and head trauma (n = 9). Among all patients, 12 fistulas (66.7%) were located at the cribriform plate area, two (11.1%) at the roof of the ethmoid sinuses, two (11.1%) in the sphenoid sinus, and two (11.1%) at the frontal sinus. The maximum diameters of fistulas ranged from 5 to 20 mm, with a median value of 8 mm. Encephaloceles were identified in 14 (77.8%) patients. No hydrocephalus was recognized. All CSF leaks were successfully repaired with a bath-plug technique. Follow-up ranged from 50 to 70 months. No surgical complications were encountered in any patient. Interpretation Bath-plug technique is safe and reliable for the endoscopic management of CSF leaks in children. Meticulous peri-operative preparations are important for pediatric patients.
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Affiliation(s)
- Xiaojian Yang
- Department of Otorhinolaryngology, Head and Neck Surgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Lixing Tang
- Department of Otorhinolaryngology, Head and Neck Surgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Pengpeng Wang
- Department of Otorhinolaryngology, Head and Neck Surgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Ming Ge
- Department of Neurosurgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Wei Zhang
- Department of Otorhinolaryngology, Head and Neck Surgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Xiao Xiao
- Department of Otorhinolaryngology, Head and Neck Surgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Yang Han
- Department of Otorhinolaryngology, Head and Neck Surgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Wentong Ge
- Department of Otorhinolaryngology, Head and Neck Surgery Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
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Endoscopic Skull Base Surgery in Children. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Palmieri D, Champagne PO, Valappil B, McDowell MM, Gardner PA, Snyderman CH. Risk Factors in a Pediatric Population for Postoperative Intracranial Infection Following Endoscopic Endonasal Skull Base Surgery and the Role of Antibiotic Prophylaxis. Am J Rhinol Allergy 2022; 37:13-18. [PMID: 36050937 DOI: 10.1177/19458924221123113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endoscopic endonasal skull base surgery (EESBS) is performed through a non-sterile corridor. Intracranial infection rates in a pediatric population have not been extensively studied and the exact effect of antibiotic prophylaxis on rates of infection after EESBS in pediatric patients remains unclear. OBJECTIVE The purpose of our study is to investigate risk factors for postoperative intracranial infection during EESBS in a pediatric population and help elucidate the role of antibiotic prophylaxis. METHODS We conducted a retrospective chart review of 99 consecutive patients under the age of 18 who underwent EESBS at our institution from 2013 to 2021. Centers for Disease Control and Prevention/National Healthcare Safety Network criteria for diagnosis of meningitis were used to identify postoperative intracranial infections. RESULTS The average age was 12.3 years (range 1.6-18) with 66 male patients and 33 female patients. 49 patients had an intraoperative cerebrospinal fluid (CSF) leak, of which 4 had a postoperative CSF leak. We identified 3 postoperative intracranial infections (3%), which were all meningitis cases. The infection rate was 6% (3/49) among those with intraoperative CSF leaks. All patients with meningitis had a postoperative CSF leak. All infections were transclival approaches (2 chordoma and 1 neurenteric cyst). CONCLUSION This investigation represents one of the largest pediatric endoscopic skull base surgery cohorts. EESBS is safe to perform in pediatric populations, but transclival approaches and postoperative CSF leaks are risk factors for postoperative meningitis.
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Affiliation(s)
- Daniel Palmieri
- 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Pierre-Olivier Champagne
- Department of Neurological Surgery, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Benita Valappil
- Department of Otolaryngology, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael M McDowell
- Department of Neurological Surgery, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul A Gardner
- Department of Neurological Surgery, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carl H Snyderman
- Department of Otolaryngology, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Liu Z, Zhao L, Wang Y, Dai K, Lu A, Zhao P. Application of dural suturing in the endoscopic endonasal approach to the sellar region. Front Surg 2022; 9:944663. [PMID: 36061055 PMCID: PMC9433994 DOI: 10.3389/fsurg.2022.944663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThe endoscopic endonasal approach (EEA) is widely used in the treatment of cranial base tumors. Skull base reconstruction is a crucial part of EEA, which has a great impact on patients’ prognosis. In this study, we report our experience with sellar dural suturing in cranial base reconstruction and retrospectively analyze its effect.MethodsThe clinical data of 134 patients who suffered intraoperative CSF leakage and underwent EEA surgery in the Department of Neurosurgery of the First Affiliated Hospital of Nanjing Medical University from October 2018 to November 2020 were retrospectively collected and analyzed. According to whether sellar dural suturing was performed during the operation, they were divided into a suture group (55 cases) and a control group (79 cases).ResultsThe results showed that dural suturing of the sellar floor effectively reduced the postoperative hospitalization duration (p = 0.026) and the use rates of lumbar drainage (p = 0.047), autologous fat transplantation (p = 0.038), and pedicled nasoseptal flaps (p = 0.026).ConclusionSellar dural suturing under endoscopy is a promising and effective method for cranial base reconstruction in EEA surgery and is worthy of clinical application.
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Torres-Bayona S, Velasquez N, Nakassa A, Eguiluz-Melendez A, Hernandez V, Vega B, Borghei-Razavi H, Miranda-Acosta Y, Wang EW, Snyderman CH, Gardner PA. Risk Factors and Reconstruction Techniques for Persistent Cerebrospinal Fluid Leak in Patients Undergoing Endoscopic Endonasal Approach to the Posterior Fossa. Skull Base Surg 2022; 83:e318-e323. [DOI: 10.1055/s-0041-1729904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/24/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Background High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks.
Objective This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair.
Methods Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors.
Results Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) (p = 0.02). All patients with a persistent CSF leak developed meningitis (p = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair.
Conclusion Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial–pericranial flaps, should be considered as an early rescue option in obese patients.
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Affiliation(s)
- Sergio Torres-Bayona
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Department of Neurosurgery, Instituto Neurológico, Hospital Internacional de Colombia, Bucaramanga, Colombia
- Department of Neurological Surgery and Spine Unit, Los Cobos Medical Center, Bogotá, Colombia
- School of Medicine, Grupo de Investigación básica y traslacional—GIBAT, Universidad El Bosque, Bogotá, Colombia
| | - Nathalia Velasquez
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Ana Nakassa
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Aldo Eguiluz-Melendez
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Vanessa Hernandez
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Belen Vega
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Hamid Borghei-Razavi
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, United States
| | - Yeiris Miranda-Acosta
- Department of Neurosurgery, Instituto Neurológico, Hospital Internacional de Colombia, Bucaramanga, Colombia
| | - Eric W. Wang
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H. Snyderman
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A. Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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14
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Patel TD, Rullan-Oliver B, Ungerer H, Storm PB, Kohanski MA, Adappa ND, Palmer JN. Outcomes of endoscopic endonasal resection of pediatric craniopharyngiomas. Int Forum Allergy Rhinol 2022; 12:1517-1526. [PMID: 35485414 DOI: 10.1002/alr.23009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/02/2022] [Accepted: 04/06/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Craniopharyngiomas have traditionally been treated via open transcranial approaches. More recent, endoscopic endonasal approaches have been increasingly used; however, there has been limited evaluation of long-term outcomes for this approach. METHODS A retrospective review was performed to analyze patients with pediatric craniopharyngioma undergoing endonasal endoscopic resection from 2012 to 2020. Demographic information, clinicopathologic factors, and outcomes including follow-up and recurrences were analyzed. RESULTS All 42 patients, with a mean age of 8.0 years, were included. The median follow-up time was 49 months. Mean tumor diameter was 3.6 cm. All of the tumors had sellar and suprasellar components. The most common presenting symptoms were headaches (64.3%), visual changes (59.5%), and nausea/vomiting (38.1%). Most patients (73.3%) had resolution of their presenting symptoms by their first postoperative visit. Vision improved or remained normal in 69.0% of patients. Postoperatively, incidence of panhypopituitarism or diabetes insipidus developed in 89.7% and 77.8% of patients, respectively. The postoperative cerebrospinal fluid leak rate was 7.1%. The recurrence rate was 9.5%. CONCLUSION Endoscopic endonasal resection for pediatric craniopharyngiomas can achieve high rates of resection with low rates of disease recurrence when compared with the outcomes of open transcranial resection reported in the literature. However, hypothalamic-pituitary dysfunction remains a significant postoperative morbidity in both approaches.
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Affiliation(s)
- Tapan D Patel
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Health System, Philadelphia, Pennsylvania, USA
| | - Bianca Rullan-Oliver
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Health System, Philadelphia, Pennsylvania, USA
| | - Heather Ungerer
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Health System, Philadelphia, Pennsylvania, USA
| | - Phillip B Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Michael A Kohanski
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Health System, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Health System, Philadelphia, Pennsylvania, USA
| | - James N Palmer
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Health System, Philadelphia, Pennsylvania, USA
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15
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Affum JAD, Horsley E. 'She's sprung a leak': Significant cerebrospinal fluid leak in an infant post-lumbar puncture. J Paediatr Child Health 2022; 58:521-523. [PMID: 33998724 DOI: 10.1111/jpc.15547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Juliet A D Affum
- General Paediatrics, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Emily Horsley
- General Paediatrics, Queensland Children's Hospital, Brisbane, Queensland, Australia
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16
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Madsen PJ, Lang SS, Adappa ND, Palmer JN, Storm PB. Pediatric Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:477-491. [DOI: 10.1016/j.otc.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Wu D, Xu L, Xie S, Sun F, Xie M, Wang P, Xiao S. Extended Neuroendoscopic Endonasal Approach for Resection of Craniopharyngioma in Children. Front Neurol 2022; 13:771236. [PMID: 35173672 PMCID: PMC8841857 DOI: 10.3389/fneur.2022.771236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To explore the surgical approach and technique of neuroendoscopic endonasal resection of pediatric craniopharyngiomas and to further evaluate its safety and effect in children. Methods The clinical data of 8 children with craniopharyngiomas who were surgically treated by neuroendoscopy through an extended endonasal approach in our center from 2018 to 2021 were retrospectively analyzed. The related surgical approach and technique were evaluated to improve the surgical results and further reduce the surgical complications when removing craniopharyngioma in children. Results All 8 patients achieved a gross-total resection of the tumor under neuroendoscopy. Postoperatively, 2 cases of transient hyperthermia and 4 cases of transient hyper- and/or hyponatremia occurred within the first 2 weeks, all of which were quickly controlled. Seven patients had symptoms of diabetes insipidus to varying degrees after the operation, and 4 of them improved within 1–3 months after surgery, but 3 cases still needed oral pituitrin. There were no cases of coma or death, leakage of cerebrospinal fluid, or severe electrolyte imbalance after surgery. During the postoperative follow-up of 3 months to 2 years, no tumor recurrence was found. Among the 7 patients who suffered postoperative neuroendocrine deficiencies, 3 patients were found to be temporary during the follow-up, but 4 patients still required hormone replacement therapy. Particularly, postoperative visual deterioration and olfactory defect that occurred in patients were all improved during follow-up periods. In addition, 4 cases of obesity were noted at the last follow-up. Conclusions Extended neuroendoscopic endonasal resection of craniopharyngiomas may be used as a safe and effective approach for children. Due to the poor pneumatization of the sphenoid sinus and worse compliance of treatment in children, surgical techniques of exposing the sellar region, removing the tumor, and reconstructing the skull base, as well as postoperative management of patients was proposed. However, due to the limited surgical cases in the study, the surgical safety and effects of the extended neuroendoscopic endonasal approach for children with craniopharyngiomas need to be further studied in the future.
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Affiliation(s)
- Danyang Wu
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ling Xu
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Sungel Xie
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Feiji Sun
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Mingxiang Xie
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Graduate School, Zunyi Medical University, Zunyi, China
| | - Pei Wang
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shunwu Xiao
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Graduate School, Zunyi Medical University, Zunyi, China
- *Correspondence: Shunwu Xiao ; orcid.org/0000-0002-3690-4963
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18
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Reardon T, Marsh C, Rippe P, Ruzys D, Ayres B, Cline D, Fiani B. Clinical management of pediatric chordomas: a comprehensive review. Acta Neurol Belg 2021; 121:1407-1414. [PMID: 34648142 DOI: 10.1007/s13760-021-01821-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
Chordomas are malignant tumors derived from remnants of the notochord. These are extremely rare in pediatric patients, accounting for approximately 5% of all chordomas, with most lesions occupying the cranium. Chordomas also can occupy all levels of the spine, demonstrating a broad spectrum of neurologic presentation. Optimal treatment aims for gross total resection with accompanying radiation therapy to prevent recurrence. Their aggressive and infiltrative nature makes clinical management challenging, involving multiple disciplines and close monitoring to ensure optimal outcomes. This comprehensive review aims to cover the genetics, demographics, pathogenesis, neurologic sequelae, radiological considerations, chemotherapeutic management, surgical management, and post-operative considerations of pediatric chordoma patients.
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Affiliation(s)
- Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA.
| | - Caleb Marsh
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA
| | - Preston Rippe
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA
| | - Donatas Ruzys
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA
| | - Benjamin Ayres
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA
| | - David Cline
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA
| | - Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
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19
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Papagiannopoulos P, Tong CCL, Brown HJ, Douglas JE, Yver CM, Kuan EC, Tajudeen BA, Kohanski MA, LeeMSCE JYK, Palmer JN, W O'Malley B, Grady MS, Storm PB, Adappa ND. Comparison of high-flow CSF leak closure with nasoseptal flap following endoscopic endonasal approach in adult and pediatric populations. Int Forum Allergy Rhinol 2021; 12:321-323. [PMID: 34719119 DOI: 10.1002/alr.22910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Peter Papagiannopoulos
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles C L Tong
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hannah J Brown
- Rush Medical College, Rush University Medical Center, Chicago, Illinois, USA
| | - Jennifer E Douglas
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina M Yver
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward C Kuan
- Department of Otorhinolaryngology - Head and Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Bobby A Tajudeen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael A Kohanski
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K LeeMSCE
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James N Palmer
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bert W O'Malley
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - M Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Phillip B Storm
- Department of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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20
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Dorismond C, Santarelli GD, Thorp BD, Kimple AJ, Ebert CS, Zanation AM. Heterogeneity in Outcome Reporting in Endoscopic Endonasal Skull Base Reconstruction: A Systematic Review. J Neurol Surg B Skull Base 2021; 82:506-521. [PMID: 34513556 DOI: 10.1055/s-0040-1714108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/17/2020] [Indexed: 10/23/2022] Open
Abstract
Objective Presently, there are no standards for reporting outcomes of endoscopic endonasal skull base reconstruction (ESBR). This is problematic as a lack of consistent reporting makes synthesizing findings in systematic reviews and meta-analysis challenging. Thus, the aim of this study was to systematically review and describe the patterns of reporting outcomes in ESBR as a foundation for developing reporting guidelines. Study Design Present study is a systematic review. Methods Embase, PubMed, CINAHL, Cochrane Library, and Web of Science were searched for all publications with ≥25 patients and a focus on ESBR. The reporting patterns of each study's variables and outcomes were assessed. Results A total of 112 studies were included in the review. The most commonly reported demographic variables were the number of included patients ( n = 112, 100%) and types of pathologies treated ( n = 104, 92.9%). Meanwhile, the most routinely described preoperative variable was history of prior treatment ( n = 48, 42.9%). Type of reconstruction was a commonly reported intraoperative variable ( n = 110, 98.2%), though the rate of intraoperative cerebrospinal fluid (CSF) leak was noted in only 76 studies (67.9%). With regard to postoperative outcomes, postoperative CSF leak rate was routinely provided ( n = 101, 90.2%), but reporting of other surgical complications was more inconsistent. Ultimately, of the 43 variables and outcomes reviewed, a median of 12 (range: 4-22) was reported in each study. Conclusion There is significant heterogeneity in the outcomes reported in studies relating to ESBR. This highlights the need for the development of standard reporting guidelines to minimize bias and improve interstudy comparability.
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Affiliation(s)
- Christina Dorismond
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Griffin D Santarelli
- Department of Otolaryngology, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Brian D Thorp
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Adam J Kimple
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Charles S Ebert
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Adam M Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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21
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Ballestero MFM, de Souza SNF, Pacheco Neto RC, Gondim GGP, Valera ET, Dos Reis MBF, Colli BO, de Oliveira RS. Pediatric Skull Base Tumors: A Management Challenge. J Pediatr Neurosci 2021; 16:35-43. [PMID: 34316306 PMCID: PMC8276951 DOI: 10.4103/jpn.jpn_56_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/29/2020] [Accepted: 08/17/2020] [Indexed: 12/29/2022] Open
Abstract
Context Skull base tumors are varied in children and are particularly challenging to pediatric neurosurgeons, with few papers in the literature describing the evolution, complications, and outcome. The authors evaluated long-term outcomes in children submitted to skull base tumor surgery and performed a literature review. Aims The aim of this study was to analyze surgical results, complications, and outcomes, on comparison with previous publications. Materials and Methods A retrospective analysis of children undergoing surgery at a single institution between 2000 and 2018 for lesions of the cranial base was carried out. In addition, a literature review was carried out describing a total of 115 children operated on for skull base tumors. Statistical Analysis Chi-squared and Fisher's exact tests were performed to compare the distribution of categorical variables and a nonparametric Mann-Whitney U test was used to perform intergroup comparisons of continuous variables. Results Seventeen children ranging in age from 8 months to 17 years (mean, 10.9 years) underwent skull base approaches. Tumor types included schwannoma, meningioma, chondroid chordoma, mature teratoma, epidermoid cyst, hemangiopericytoma, rhabdomyosarcoma, myofibroblastic inflammatory tumor, fibromyxoid sarcoma, Crooke's cell adenoma, ossifying fibroma, osteoblastoma, nasopharyngeal angiofibroma and Ewing's sarcoma. Gross total resection was achieved in 6 patients (35.3%), 12 patients (70.6%) had benign histology, and 5 patients (29.4%) had a malignant tumor. Transient postoperative cerebrospinal fluid leak affected only one patient. Thirteen children (76.4%) had a residual neurological deficit at last follow-up evaluation. Three (17.6%) surviving patients received adjuvant therapy. The rate of recurrence or lesion progression was 17.6%. Conclusions Skull base tumors in children present a therapeutic challenge because of their unique pathological composition and can lead to considerable morbidity and mortality in pediatric age.
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Affiliation(s)
- Matheus F M Ballestero
- Department of Medicine, Federal University of São Carlos, São Carlos, Brazil.,Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Stephanie N F de Souza
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Romilto C Pacheco Neto
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Guilherme G P Gondim
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Elvis T Valera
- Division of Pediatric Neuroncology, Department of Pediatrics, Ribeirão Preto Medical School, University of Sao Paulo, São Carlos, Brazil
| | - Maristella B F Dos Reis
- Division of Pediatric Neuroncology, Department of Pediatrics, Ribeirão Preto Medical School, University of Sao Paulo, São Carlos, Brazil
| | - Benedicto O Colli
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ricardo S de Oliveira
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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22
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Xu JC, Lehrich BM, Yasaka TM, Fong BM, Hsu FPK, Kuan EC. Characteristics and overall survival in pediatric versus adult skull base chordoma: a population-based study. Childs Nerv Syst 2021; 37:1901-1908. [PMID: 33459820 DOI: 10.1007/s00381-021-05046-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Less than 5% of chordomas occur in pediatric patients. While many studies have explored the treatment and outcomes of skull base chordomas, few have focused on the differences between pediatric and adult populations. The aim of this study is to analyze the epidemiological variables and clinical outcomes between pediatric and adult skull base chordomas using a large-sample, population-based cancer database. METHODS The National Cancer Database was queried between 2004 and 2015 for skull base chordomas. We stratified patients as pediatric (<18 years) and adults (≥18 years). We compared several clinical covariates between the two groups. RESULTS Our cohort consisted of 658 patients, 61 pediatric (9.3%), and 597 adults (90.7%). Pediatric patients were more likely to have larger tumor size (41.4 ± 15.7 mm versus 34.1 ± 15.8 mm, p < 0.01) and universally treated at academic facilities. There was no significant difference in overall survival. CONCLUSIONS Pediatric skull base chordomas are rare tumors that are managed with aggressive surgical resection, followed by radiation. While there may be difference between tumor presentation, outcomes between pediatric and adult patients are similar.
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Affiliation(s)
- Jordan C Xu
- Department of Neurosurgery, University of California, Irvine, CA, USA
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh and Carnegie Mellon University, Pittsburgh, PA, USA
| | - Tyler M Yasaka
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Brendan M Fong
- Department of Neurosurgery, University of California, Irvine, CA, USA
| | - Frank P K Hsu
- Department of Neurosurgery, University of California, Irvine, CA, USA
| | - Edward C Kuan
- Department of Neurosurgery, University of California, Irvine, CA, USA. .,Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.
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23
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McDowell MM, Chiang M, Abou-Al-Shaar H, Zenonos GA, Wang EW, Snyderman CH, Gardner PA. Applications of Endoscopic Endonasal Surgery in Early Childhood: A Case Series. Pediatr Neurosurg 2021; 56:519-528. [PMID: 34518465 DOI: 10.1159/000518681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Endoscopic endonasal surgery (EES) has been slower to gain popularity in early childhood due to anatomical challenges. We sought to describe the safety and efficacy of EES in early childhood. METHODS All patients younger than 7 years who underwent EES at a large Cranial Base Center from 2002 to 2019 were reviewed as a retrospective cohort study. RESULTS Thirty-six patients underwent EES before the age of 7 years. Four patients had two-stage EES. Two patients required combined transcranial and endonasal approaches. The mean age at the time of initial surgery was 4 years (range: 1-6). Twenty patients were male, and 16 were female. Of 21 tumors intended for resection, 11 patients had gross total resections, and 10 had near total (>95% tumor removed) resections. Nine patients (43%) had recurrences, of which 6 were craniopharyngiomas (p = 0.01). There was no difference in recurrence rates based on the degree of resection (p = 0.67). Three cerebrospinal fluid (CSF) leaks occurred following primary EES (8%). Following an increase in nasoseptal flap usage (31-52%) and CSF diversion (15-39%) in 2008, there was only one CSF leak out of 23 patients (4 vs. 15%; p = 0.54). Postoperatively, 1 patient developed a permanent new cranial neuropathy, and 1 patient developed a permanent visual field cut. Six patients developed permanent postoperative panhypopituitarism, of which all were craniopharyngiomas (p < 0.001). The mean follow-up was 64 months. CONCLUSIONS Early childhood EES is both safe and technically feasible for a variety of pathologies.
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Affiliation(s)
- Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Chiang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Georgios A Zenonos
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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24
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Rampinelli V, Mattavelli D, Ferrari M, Schreiber A, Ravanelli M, Farina D, Deganello A, Fontanella MM, Doglietto F, Nicolai P. Management of anterior fossa cephaloceles. J Neurosurg Sci 2020; 65:140-150. [PMID: 33320465 DOI: 10.23736/s0390-5616.20.05099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Skull base cephaloceles (SBCs) are defined as herniation of intracranial content through the skull base and are classified based on composition, etiology, and topographic location. Anterior SBCs frequently protrude in the sinonasal cavity, and consequently are at potential risk of infection. Therefore, the current recommendation is to treat SBCs with the primary intent of preventing meningitis, and surgery represents the mainstay of treatment. Anterior SBCs may display a wide spectrum of severity and complexity, and in each case the risks and benefits of surgical approaches are to be carefully weighted based on thorough assessment of symptoms, age, general conditions, location and size of the lesion, as well as expertise of the surgeon. In the last 30 years, the evolution and diffusion of transnasal endoscopic surgery have substantially changed the surgical management of the majority of SBC. In the past, they were treated exclusively with open transcranial approaches that may be burdened by relevant morbidity and risk for severe complications. The transnasal endoscopic corridor now provides easy access to the lesion and different reconstructive strategies using endonasal pedicled flaps, without any external incision, cranioplasty or brain manipulation. However, there are still scenarios in which an exclusive transnasal endoscopic route is contraindicated. The aim of the present review was to provide an overview on the comprehensive management of anterior SBC, with a particular focus on lesions suitable for endoscopic surgery. Furthermore, special aspects of SBC management in children and adults will be highlighted.
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Affiliation(s)
- Vittorio Rampinelli
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Section of Otorhinolaryngology, Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Farina
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy -
| | - Piero Nicolai
- Section of Otorhinolaryngology, Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
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25
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London NR, Rangel GG, Onwuka A, Carrau RL, Prevedello DM, Leonard JA, Walz PC. Reconstruction of pediatric skull base defects: A retrospective analysis emphasizing the very young. Int J Pediatr Otorhinolaryngol 2020; 133:109962. [PMID: 32109673 DOI: 10.1016/j.ijporl.2020.109962] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/14/2020] [Accepted: 02/15/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Pathology of the pediatric skull base is rare and ranges from congenital defects to malignancy and traumatic defects. Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic challenges for the skull base surgeon. The goal of this study was to retrospectively review our experience with reconstruction of pediatric skull base defects with particular emphasis on those ≤6 years of age. METHODS A retrospective chart review was conducted of patients ≤20 years of age who underwent endoscopic endonasal and combined endoscopic and open approaches to address cranial base pathology from 2007 to 2018. Patients were divided into two groups; those ≤6 years of age (group A) and those >6 years of age and ≤20 years of age (group B) and reconstructive techniques and outcomes were analyzed. RESULTS Intraoperative communication with the subarachnoid space (CSF leak) was created in 50% (3/6) of patients ≤ 6 years of age compared to 32.7% (16/49) in patients > 6 years and ≤20 years of age (P < 0.40) in management of their skull base disease. A vascularized flap was utilized for reconstruction in 66.7% (4/6) of patients ≤ 6 years of age and included a nasoseptal flap in 33.3% (2/6). A vascularized flap was utilized for reconstruction in 38.8% (19/49) of patients > 6 years and ≤20 years of age and most commonly included a nasoseptal flap (22.4%, 11/49). A lumbar drain was utilized in 50% (3/6) of patients ≤ 6 years of age compared to 18.4% (9/49) in patients > 6 and ≤20 years of age (P < 0.08). Post-operative CSF leaks were encountered in 16.7% (1/6) of patients ≤ 6 years of age compared to 10.2% (5/49) in patients > 6 and ≤20 years of age (P < 0.63). Behavioral issues were noted to potentially contribute to failed skull base reconstruction in patients <6 years of age. CONCLUSIONS Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic and behavioral challenges for the skull base surgeon as highlighted in this study.
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Affiliation(s)
- Nyall R London
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Otolaryngology Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA; Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, MD, USA
| | - Gustavo G Rangel
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Jeffrey A Leonard
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick C Walz
- Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, OH, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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London NR, Mohyeldin A, Montaser AS, Tanjararak K, Prevedello DM, Otto BA, Carrau RL. Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm. Int Forum Allergy Rhinol 2020; 10:779-784. [DOI: 10.1002/alr.22544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/22/2019] [Accepted: 02/05/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Nyall R. London
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins University Baltimore MD
- National Institute on Deafness and Other Communication DisordersNational Institutes of Health Bethesda MD
| | - Ahmed Mohyeldin
- Department of NeurosurgeryThe Ohio State University Columbus OH
| | - Alla S. Montaser
- Department of NeurosurgeryAin Shams University Faculty of Medicine Cairo Egypt
| | - Kangsadarn Tanjararak
- Department of Otolaryngology Head and Neck SurgeryRamathibodi Hospital Faculty of MedicineMahidol University Bangkok Thailand
| | - Daniel M. Prevedello
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of NeurosurgeryThe Ohio State University Columbus OH
| | - Bradley A. Otto
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of NeurosurgeryThe Ohio State University Columbus OH
| | - Ricardo L. Carrau
- Department of Otolaryngology‒Head and Neck SurgeryThe Ohio State University Columbus OH
- Department of NeurosurgeryThe Ohio State University Columbus OH
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Endonasal endoscopic surgery for pediatric anterior cranial fossa encephaloceles: A systematic review. Int J Pediatr Otorhinolaryngol 2020; 132:109919. [PMID: 32036168 DOI: 10.1016/j.ijporl.2020.109919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic endonasal skull base surgery (ESBS) is a well-established management strategy for anterior cranial fossa (ACF) encephaloceles in adults. However, its application to the pediatric population has not been evaluated in large-scale studies. This study systematically reviews the safety of ESBS for pediatric ACF encephaloceles. METHODS Articles reporting on pediatric patients undergoing purely ESBS for encephaloceles were reviewed from three databases (PubMed, Scopus, and Cochrane Library). Main outcomes were post-operative cerebrospinal fluid (CSF) leak and other surgical complications. RESULTS Twenty-three articles provided data on 110 eligible patients with a mean age of 4.3 years (range birth - 18 years). Intraoperative CSF leaks occurred in 18.5% of children while post-operative CSF leaks developed in 6.0% of cases. Rates of meningitis and hydrocephalus were each 3.7%. Other complications included alar collapse, nasal stenosis, transient diabetes insipidus, pneumonia, and neurologic injury, collectively occurring in 7.0% of cases. The rate of death was 4.8%. The average duration of follow-up was 25.3 months. Encephaloceles recurred in 5.2% of patients. CONCLUSIONS ESBS for pediatric ACF encephaloceles provides a relatively favorable risk-benefit profile, with a low rate of post-operative CSF leak, other surgical complications, and disease recurrence.
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Yaniv D, Soudry E, Strenov Y, Cohen MA, Mizrachi A. Skull base chordomas review of current treatment paradigms. World J Otorhinolaryngol Head Neck Surg 2020; 6:125-131. [PMID: 32596658 PMCID: PMC7296475 DOI: 10.1016/j.wjorl.2020.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 01/19/2020] [Indexed: 11/04/2022] Open
Abstract
Background Chordomas are locally invasive neoplasms, arising from notochordal remnants and can appear anywhere along the axial skeleton. Local recurrences are common, and distant metastases may occur years after the initial presentation. Methods Literature review of current treatment strategies for chordomas of the skull base. Results Surgery is the mainstay of treatment and complete resection has paramount importance for prognosis. When complete resection is not achieved recurrent disease is common. The anatomical complexity of the skull base makes resection complex. Endonasal endoscopic approaches to the clivus has become increasingly favored in recent years although addressing reconstruction of the skull base to prevent CSF leak may be challenging. Evidence suggests that radiotherapy should not be considered as a primary single modality when trying to achieve cure of the disease. Nonetheless, immediate post-operative radiotherapy improves survival. Many strategies have been suggested to preserve sensitive vital structures in the skull base during treatment but as for survival there is no evidence of advantage when comparing adjuvant therapy with photon radiotherapy, gamma knife surgery, proton beam therapy, and carbon ion radiation therapy. There is no evidence to support cytotoxic chemotherapy in the treatment of chordomas but targeted therapies have started to show promise. Several optional molecular targets exist. Brachyury is overexpressed in 95% of chordomas but not in other mesenchymal neoplasms. However, its precise role in chordoma pathogenesis is currently unclear, and its cellular location in the nucleus makes it difficult to target. The inhibition of brachyury in chordoma cell lines induces growth arrest and apoptosis. This does not have clinical application to date. There are retrospective results with different molecular targeted therapies for advanced chordomas with some effectiveness. Conclusion Despite improvements made in the past 10 years in our knowledge of chordoma biology, available therapies still offer a limited benefit. There is an unmet need for new therapeutic options for patients with advanced disease. Therefore, patients with advanced disease should be encouraged to participate in clinical trials when and where available.
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Affiliation(s)
- Dan Yaniv
- Department of Otolaryngology- Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ethan Soudry
- Department of Otolaryngology- Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Strenov
- Department of Pathology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marc A Cohen
- Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Aviram Mizrachi
- Department of Otolaryngology- Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Riley CA, Soneru CP, Overdevest JB, Otten ML, Gudis DA. Pediatric sinonasal and skull base lesions. World J Otorhinolaryngol Head Neck Surg 2020; 6:118-124. [PMID: 32596657 PMCID: PMC7296510 DOI: 10.1016/j.wjorl.2020.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 01/18/2020] [Indexed: 12/13/2022] Open
Abstract
Pediatric skull base lesions are complex and challenging disorders. Safe and comprehensive management of this diverse group of disorders requires the expertise of an experienced multidisciplinary skull base team. Adult endoscopic skull base surgery has evolved due to technologic and surgical advancements, multidisciplinary team approaches, and continued innovation. Similar principles continue to advance the care delivered to the pediatric population. The approach and management of these lesions varies considerably based on tumor anatomy, pathology, and surgical goals. An understanding of the nuances of skull base reconstruction unique to the pediatric population is critical for successful outcomes.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Christian P Soneru
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Jonathan B Overdevest
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - Marc L Otten
- Department of Neurological Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
| | - David A Gudis
- Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
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London NR, Rangel GG, Walz PC. The expanded endonasal approach in pediatric skull base surgery: A review. Laryngoscope Investig Otolaryngol 2020; 5:313-325. [PMID: 32337363 PMCID: PMC7178460 DOI: 10.1002/lio2.369] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Surgery of the pediatric skull base has multiple unique challenges and has seen recent rapid advances. The objective of this review is to assess key issues in pediatric skull base surgery (SBS), including anatomic limitations, surgical approaches, reconstruction techniques, postoperative care, complications, and outcomes. DATA SOURCES PubMed literature review. REVIEW METHODS A review of the literature was conducted to assess the challenges, recent advances, and reported outcomes in pediatric SBS. RESULTS The pediatric skull base presents multiple anatomic challenges, including variable patterns of pneumatization, narrow piriform aperture width, and narrow intercarotid distance at the level of the cavernous sinus but not the superior clivus. These issues may be particularly challenging in patients less than 2 years of age. Endoscopic endonasal approaches in the sagittal and coronal plane have been applied to the pediatric skull base while open approaches may still be necessary in the setting of extensive intracranial or orbital disease, as well as disease lateral to critical neurovascular structures. While the nasoseptal flap was initially called into question for pediatric cases, it has been shown through multiple reports to be a feasible and robust reconstructive option. Complications and outcomes often depend upon the pathology. In children, response to noxious stimuli, ability to avoid Valsalva, and adherence to nasal precautions is variable. The use of lumbar drains is more common in pediatric than adult patients. CONCLUSION While the pediatric skull base presents unique challenges, outcomes data support that endoscopic endonasal approaches are a pertinent surgical technique in appropriately selected patients. LEVEL OF EVIDENCE 3a.
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Affiliation(s)
- Nyall R. London
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Otolaryngology‐Head and Neck SurgeryJohns Hopkins School of MedicineBaltimoreMarylandUSA
- National Institute on Deafness and Other Communication DisordersNIHBethesdaMarylandUSA
| | - Gustavo G. Rangel
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
| | - Patrick C. Walz
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
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Lee JA, Cooper RL, Nguyen SA, Schlosser RJ, Gudis DA. Endonasal Endoscopic Surgery for Pediatric Sellar and Suprasellar Lesions: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 163:284-292. [PMID: 32204653 DOI: 10.1177/0194599820913637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The advent of endonasal endoscopic skull base surgery (ESBS) has redefined the management of pediatric sellar and suprasellar lesions. To date, the outcomes of these procedures have not been systematically reviewed. This study performed a systematic review with meta-analysis of surgical outcomes for pediatric patients undergoing ESBS for sellar and suprasellar lesions. DATA SOURCES PubMed (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and Cochrane Library (Wiley). REVIEW METHODS Articles reporting on pediatric patients undergoing ESBS for craniopharyngiomas, pituitary adenomas, and Rathke's cleft cysts were reviewed. The primary outcome was postoperative cerebrospinal fluid (CSF) leak. Secondary outcomes included endocrine, visual, and other complications. RESULTS Twenty-five articles reporting on 554 patients were included. Overall postoperative CSF leak rate was 8.6%, with tumor-specific rates of 10.6% in craniopharyngiomas, 6.5% in pituitary adenomas, and 7.2% in Rathke's cleft cysts (P > .05). Older studies demonstrate higher postoperative CSF leak rates as compared with more recent studies (12.5% vs 6.1%, P = .0082). Younger children (8.9-12.6 years old) experienced a higher rate of postoperative CSF leaks as compared with older children (13.0-16.6 years old; 12.9% vs 4.9%, P = .0016). Additional postoperative complications included diabetes insipidus (26.7%), hypopituitarism (46.6%), visual deficits (2.6%), meningitis (3.4%), and weight gain (3.4%). CONCLUSION ESBS for pediatric sellar and suprasellar lesions is overall an effective management approach with an increasingly favorable risk-benefit profile. Younger children may be more susceptible to postoperative CSF leak as compared with older pediatric patients. Tumor type does not appear to be an independent risk factor for postoperative CSF leak in this population.
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Affiliation(s)
- Joshua A Lee
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rebecca L Cooper
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Soldozy S, Yeghyayan M, Yağmurlu K, Norat P, Taylor DG, Kalani MYS, Jane JA, Syed HR. Endoscopic endonasal surgery outcomes for pediatric craniopharyngioma: a systematic review. Neurosurg Focus 2020; 48:E6. [DOI: 10.3171/2019.10.focus19728] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 10/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to systematically review the outcomes of endoscopic endonasal surgery (EES) for pediatric craniopharyngiomas so as to assess its safety and efficacy.METHODSA systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2019. All studies assessing outcomes following EES for pediatric craniopharyngiomas were included.RESULTSOf the total 48 articles identified in the original literature search, 13 studies were ultimately selected. This includes comparative studies with other surgical approaches, retrospective cohort studies, and case series.CONCLUSIONSEES for pediatric craniopharyngiomas is a safe and efficacious alternative to other surgical approaches. Achieving gross-total resection with minimal complications is feasible with EES and is comparable, if not superior in some cases, to traditional means of resection. Ideally, a randomized controlled trial might be implemented in the future to further elucidate the effectiveness of EES for resection of craniopharyngiomas.
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Deopujari CE, Shah NJ, Shaikh ST, Karmarkar VS, Mohanty CB. Endonasal endoscopic skullbase surgery in children. Childs Nerv Syst 2019; 35:2091-2098. [PMID: 31079184 DOI: 10.1007/s00381-019-04167-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/17/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The role of endonasal endoscopic approach for pathologies in the paediatric population is evolving and has still not been accepted as standard of care in neurosurgery. It represents a challenge in terms of narrow access, instrument manipulation and adequate reconstruction of defects. We have described our experience in 49 cases from a single neurosurgical unit in paediatric skull base surgeries through this approach over the last 12 years. MATERIAL AND METHODS A case series of 59 paediatric skull base surgeries in 49 children through endoscopic endonasal route over the last 12 years is presented. The age ranges from 4 months to 18 years. Out of 49 cases, 22 cases were of craniopharyngiomas, 8 cases of pituitary adenomas, 5 cases with CSF rhinorrhea, 5 cases with meningoencephalocele, 3 cases of Rathke's cleft cysts, 2 cases of odontoidectomy and 4 miscellaneous cases viz. mucocele, hypothalamic glioma, esthesioneuroblastoma and epidermoid. CSF leaks were repaired with free graft in the initial years and by vascularized flap more recently. RESULTS The goal of surgery was achieved in all but two cases in whom the tumour excision was unsatisfactory due to failure of the cyst wall to collapse after decompression. Extent of tumour excision was not compromised by the choice of this approach. Revision surgery for CSF leak was required in three patients. Local vascularized nasoseptal flap has been possible even in very young patients and has now become the standard for reconstruction. CONCLUSION In spite of the challenges posed by small nostrils and ill-developed sinuses in the paediatric age group, surgery from endoscopic endonasal corridor is possible to be carried out successfully in selected cases.
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Affiliation(s)
| | - Nishit J Shah
- Department of ENT, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Salman T Shaikh
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Vikram S Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Chandan B Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
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35
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Rawlins KW, Governale LS, Leonard JR, Elmaraghy CA, Walz PC. Recurrent Cerebrospinal Leak After Endonasal Cranial Base Surgery in a 4-Year-Old Male: Challenges for Postoperative Management. EAR, NOSE & THROAT JOURNAL 2019; 100:472S-474S. [PMID: 31640409 DOI: 10.1177/0145561319880428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kasey W Rawlins
- Department of Otolaryngology, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lance S Governale
- Department of Neurosurgery, 3463University of Florida, Gainesville, FL, USA
| | - Jeffery R Leonard
- Department of Pediatric Neurosurgery, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Charles A Elmaraghy
- Department of Otolaryngology, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Otolaryngology, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick C Walz
- Department of Otolaryngology, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Otolaryngology, 2650Nationwide Children's Hospital, Columbus, OH, USA
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36
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Management of Pediatric Sinonasal and Skull Base Lesions. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-00216-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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37
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Kahilogullari G, Meco C, Beton S, Zaimoglu M, Ozgural O, Basak H, Bozkurt M, Unlu A. Endoscopic Transnasal Skull Base Surgery in Pediatric Patients. J Neurol Surg B Skull Base 2019; 81:515-525. [PMID: 33134019 DOI: 10.1055/s-0039-1692641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 05/07/2019] [Indexed: 10/26/2022] Open
Abstract
Introduction In pediatric patients, endoscopic transnasal surgery (ETNS) poses challenges because of the small size of the developing skull and narrow endonasal corridors. Objective This study aimed to evaluate the efficacy of ETNS in children by assessing our experience of endoscopic skull base surgery. Materials and Methods All pediatric patients ( n = 54) who were eligible for surgery using only the endonasal endoscopic approach at our tertiary center between 2012 and 2018 were included in this study. The surgeries were performed simultaneously by an endoscopic skull base team of neurosurgeons and otolaryngologists. Hormonal analyses were conducted before and after surgery in all patients with sellar/parasellar lesions. Patients older than 8 years underwent smell and visual testing. Results In the 54 patients aged 1 to 17 years who underwent surgery, craniopharyngioma was the most common pathology (29.6%), followed by pituitary adenoma (22.2%). Gross total resection was achieved in 33 (76.7%) of 41 patients who underwent surgery because of the presence of tumors. All visual deficits improved, although one patient sustained olfactory deterioration. Sixteen (29.6%) patients presented with complications such as transient diabetes insipidus and temporary visual loss. Conclusions Despite anatomy-related challenges in children, adequate results can be achieved with high rates of success, and the functional and anatomical integrity of the developing skull and nose of children can be preserved. In pediatric patients, ETNS is a safe and effective option for addressing various lesions along the skull base.
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Affiliation(s)
| | - Cem Meco
- Department of Otolaryngology, Ankara University, Turkey.,Department of Otolaryngology, Salzburg Paracelsus Medical University, Salzburg, Austria
| | - Suha Beton
- Department of Otolaryngology, Ankara University, Turkey
| | - Murat Zaimoglu
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Onur Ozgural
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Hazan Basak
- Department of Otolaryngology, Ankara University, Turkey
| | - Melih Bozkurt
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Agahan Unlu
- Department of Neurosurgery, Ankara University, Ankara, Turkey
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Quon JL, Kim LH, Hwang PH, Patel ZM, Grant GA, Cheshier SH, Edwards MSB. Transnasal endoscopic approach for pediatric skull base lesions: a case series. J Neurosurg Pediatr 2019; 24:246-257. [PMID: 31200365 DOI: 10.3171/2019.4.peds18693] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/15/2019] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | - Peter H Hwang
- 2Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto; and
| | - Zara M Patel
- 2Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto; and
| | - Gerald A Grant
- 1Department of Neurosurgery and
- 3Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Stanford, California
| | - Samuel H Cheshier
- 1Department of Neurosurgery and
- 3Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Stanford, California
| | - Michael S B Edwards
- 1Department of Neurosurgery and
- 3Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Stanford, California
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The Evolution of Endoscopic Skull Base Surgery Outcomes: Defining the Edge of the Envelope. World Neurosurg 2019. [DOI: 10.1016/j.wneu.2019.01.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Nation J, Schupper AJ, Deconde A, Levy M. CSF leak after endoscopic skull base surgery in children: A single institution experience. Int J Pediatr Otorhinolaryngol 2019; 119:22-26. [PMID: 30660855 DOI: 10.1016/j.ijporl.2019.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The endoscopic expanded endonasal approach (EEA) has been shown to be a safe and effective surgical technique in the resection of pediatric skull base lesions. Cerebrospinal fluid (CSF) leaks are among the most common complications of this approach. Here we review skull base resections using EEA in pediatric patients at our single institution, to identify potential risk factors for this surgical complication. METHODS A retrospective chart review was conducted on pediatric patients at our single institution for patients 19 years-old and under, who underwent an EEA for resection of a skull base tumor. RESULTS Thirty-nine pediatric patients (ages 1-19 years) with 8 different tumor pathologies underwent an EEA for resection of their skull base tumors. 21 patients experienced an intraoperative CSF leak, of which 10 (48%) were "high-flow" leaks and 11 (52%) were "low-flow" leaks. Nasoseptal flaps were only used to repair the intraoperative "high flow" leaks (n = 10), and "low flow" and "no leaks" were repaired with allograft and fat. No patients experienced a post-operative CSF leak. CONCLUSION In our pediatric series, the skull base repair algorithm of using an NSF only in cases of "high flow" intraoperative leaks was effective, and no post-operative CSF leaks occurred. Not using an NSF in cases of "low-flow" or "no leak" cases allows for decreased anatomical disruption in the growing patient.
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Affiliation(s)
- Javan Nation
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery University of California San Diego, Division of Pediatric Rady Children's Hospital San Diego, USA; University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Alexander J Schupper
- Department of Neurosurgery, University of California San Diego, Division of Pediatric Neurosurgery Rady Children's Hospital San Diego, USA; University of California San Diego School of Medicine, La Jolla, CA, USA.
| | - Adam Deconde
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery University of California San Diego, Division of Pediatric Rady Children's Hospital San Diego, USA
| | - Michael Levy
- Department of Neurosurgery, University of California San Diego, Division of Pediatric Neurosurgery Rady Children's Hospital San Diego, USA; University of California San Diego School of Medicine, La Jolla, CA, USA
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Schwartz TH, Morgenstern PF, Anand VK. Lessons learned in the evolution of endoscopic skull base surgery. J Neurosurg 2019; 130:337-346. [PMID: 30717035 DOI: 10.3171/2018.10.jns182154] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVEEndoscopic skull base surgery (ESBS) is a relatively recent addition to the neurosurgical armamentarium. As with many new approaches, there has been significant controversy regarding its value compared with more traditional approaches to ventral skull base pathology. Although early enthusiasm for new approaches that appear less invasive is usually high, these new techniques require rigorous study to ensure that widespread implementation is in the best interest of patients.METHODSThe authors compared surgical results for ESBS with transcranial surgery (TCS) for several different pathologies over two different time periods (prior to 2012 and 2012-2017) to see how results have evolved over time. Pathologies examined were craniopharyngioma, anterior skull base meningioma, esthesioneuroblastoma, chordoma, and chondrosarcoma.RESULTSESBS offers clear advantages over TCS for most craniopharyngiomas and chordomas. For well-selected cases of planum sphenoidale and tuberculum sellae meningiomas, ESBS has similar rates of resection with higher rates of visual improvement, and more recent results with lower CSF leaks make the complication rates similar between the two approaches. TCS offers a higher rate of resection with fewer complications for olfactory groove meningiomas. ESBS is preferred for lower-grade esthesioneuroblastomas, but higher-grade tumors often still require a craniofacial approach. There are few data on chondrosarcomas, but early results show that ESBS appears to offer clear advantages for minimizing morbidity with similar rates of resection, as long as surgeons are familiar with more complex inferolateral approaches.CONCLUSIONSESBS is maturing into a well-established approach that is clearly in the patients' best interest when applied by experienced surgeons for appropriate pathology. Ongoing critical reevaluation of outcomes is essential for ensuring optimal results.
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Affiliation(s)
- Theodore H Schwartz
- Departments of1Neurological Surgery and
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
- 3Department of Neuroscience, Weill Cornell Medical College, New York, New York
| | | | - Vijay K Anand
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
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Chen W, Gardner PA, Branstetter BF, Liu SD, Chang YF, Snyderman CH, Goldstein JA, Tyler-Kabara EC, Schuster LA. Long-term impact of pediatric endoscopic endonasal skull base surgery on midface growth. J Neurosurg Pediatr 2019; 23:523-530. [PMID: 30641836 DOI: 10.3171/2018.8.peds18183] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
| | - Paul A Gardner
- 2Neurosurgery
- 3Neurosurgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Shih-Dun Liu
- 5University of Pittsburgh School of Medicine; and
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Bin Abdulqader S, Al-Ajlan Z, Albakr A, Issawi W, Al-Bar M, Recinos PF, Alsaleh S, Ajlan A. Endoscopic transnasal resection of optic pathway pilocytic astrocytoma. Childs Nerv Syst 2019; 35:73-81. [PMID: 30338361 DOI: 10.1007/s00381-018-3994-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 10/10/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Optic pathway gliomas (OPGs) are low-grade neoplasms that primarily affect children. The management of OPGs remains controversial. Reports on the use of the endoscopic endonasal approach (EEA) in OPGs are extremely limited, and no such reports exist on its utility for pediatric OPGs. Here, we report our results and experience with OPGs treated with the EEA. METHODS We retrospectively reviewed the medical records of OPG patients who were treated surgically via the EEA at our institutions from 2015 to 2017. Data on the demographics, clinical presentation, surgical complications, clinical outcomes, radiological imaging, and visual outcomes were recorded for each patient. RESULTS Four cases were identified, with visual disturbances being the predominant complaint. The mean patient age was 15.5 years. Three cases showed normal preoperative hormonal profiles, but one patient had hypothyroidism. All tumors identified in this study were World Health Organization grade I pilocytic astrocytomas. Surgical complications included hypopituitarism in two patients, meningitis in two patients, cerebrospinal fluid leak in one patient, and transient diabetes insipidus in one patient. No patient experienced worsening neurological or visual symptoms postoperatively. CONCLUSIONS Although our data are preliminary, the EEA provides a direct corridor to OPG with acceptable results in terms of tumor resection and visual outcomes. Hypothalamic-pituitary axis dysfunction remains a limitation of any treatment modality for OPGs and should be considered whenever possible. Definitive conclusions are pending as the learning curve of this approach is steep. Further work is needed to understand patient selection for such an approach.
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Affiliation(s)
| | - Ziyad Al-Ajlan
- Department of Neurosurgery, King Saud University, Riyadh, Saudi Arabia
| | | | - Wisam Issawi
- Department of Neurosurgery, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed Al-Bar
- Department of Neurosurgery, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Pablo F Recinos
- Department of Neurosurgery, Cleveland Clinic Foundation, 9500 Euclid Avenue/CA-5, Cleveland, OH, 44195, USA.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, 9500 Euclid Avenue/CA-5, Cleveland, OH, 44195, USA
| | - Saad Alsaleh
- Department of Otolaryngology-Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrazag Ajlan
- Department of Neurosurgery, King Saud University, Riyadh, Saudi Arabia. .,Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, Stanford, CA, 94305, USA.
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Shenouda K, Yuhan BT, Mir A, Gonik N, Eloy JA, Liu JK, Folbe AJ, Svider PF. Endoscopic Resection of Pediatric Skull Base Tumors: An Evidence-Based Review. J Neurol Surg B Skull Base 2018; 80:527-539. [PMID: 31534896 DOI: 10.1055/s-0038-1676305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 10/13/2018] [Indexed: 10/27/2022] Open
Abstract
Objectives To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n = 239) and chondrosarcomas ( n = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n = 193, 41.2%) and endoscopic extended transsphenoidal ( n = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n = 36, 17.3%) and endocrinopathy ( n = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.
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Affiliation(s)
- Kerolos Shenouda
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Brian T Yuhan
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States.,Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan, United States
| | - Ahsan Mir
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Nathan Gonik
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States.,Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Department of Ophthalmology and Visual Science, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Department of Neurological Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - James K Liu
- Department of Otolaryngology - Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Department of Neurological Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan, United States.,Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, United States
| | - Peter F Svider
- Department of Otolaryngology - Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States
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Giovannetti F, Mussa F, Priore P, Scagnet M, Arcovio E, Valentini V, Genitori L. Endoscopic endonasal skull base surgery in pediatric patients. A single center experience. J Craniomaxillofac Surg 2018; 46:2017-2021. [DOI: 10.1016/j.jcms.2018.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 08/03/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022] Open
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46
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Zou Y, Neale N, Sun J, Yang M, Bai HX, Tang L, Zhang Z, Landi A, Wang Y, Huang RY, Zhang PJ, Li X, Xiao B, Yang L. Prognostic Factors in Clival Chordomas: An Integrated Analysis of 347 Patients. World Neurosurg 2018; 118:e375-e387. [DOI: 10.1016/j.wneu.2018.06.194] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 12/11/2022]
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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; 79:574-579. [PMID: 30456027 DOI: 10.1055/s-0038-1645854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/02/2018] [Indexed: 10/17/2022] Open
Abstract
Introduction The fully endoscopic expanded endonasal approach (EEA) has been shown to be safe and efficacious in pediatric patients. However, in the very young patient (ages six and under), 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. Here, we review skull base resections using EEA in patients aged 6 years and younger. Methods A retrospective chart review was conducted on pediatric patients age 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 and under with seven tumor pathologies underwent an EEA for the resection of their skull base tumors, with a mean follow-up of 1.45 years. Only chordoma cases required multiple-staged resections. There are no tumor recurrences to date. A high-flow intraoperative cerebrospinal fluid (CSF) leak was encountered in three cases, and there were no postoperative CSF leaks. CSF leaks were effectively repaired with NSFs. One patient suffered from postoperative hypopituitarism, one patient experienced recurrent epistaxis secondary to turbinate destruction by the tumor, and one patient expired 8 months postresection secondary to metastatic disease. Conclusion In our case series, EEA for skull base tumors in children aged 6 and under was a safe and effective surgical approach. Skull base defects are able to be effectively addressed with typical repairs including NSFs. Larger studies are warranted to further investigate this technique in this pediatric population.
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Affiliation(s)
- Javan Nation
- Department of Surgery, Division of Otolaryngology, University of California San Diego, San Diego, California, United States.,Rady Children's Hospital San Diego, San Diego, California, United States
| | - Alexander J Schupper
- University of California San Diego School of Medicine, San Diego, California, United States
| | - Adam Deconde
- Department of Surgery, Division of Otolaryngology, University of California San Diego, San Diego, California, United States
| | - Michael Levy
- Department of Neurosurgery, University of California San Diego, San Diego, California, United States.,Rady Children's Hospital San Diego, San Diego, California, United States
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Wasserzug O, DeRowe A, Ringel B, Fishman G, Fliss DM. Open Approaches to the Anterior Skull Base in Children: Review of the Literature. J Neurol Surg B Skull Base 2018; 79:42-46. [PMID: 29404240 DOI: 10.1055/s-0037-1621739] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Introduction Skull base lesions in children and adolescents are rare, and comprise only 5.6% of all skull base surgery. Anterior skull base lesions dominate, averaging slightly more than 50% of the cases. Until recently, surgery of the anterior skull base was dominated by open procedures and endoscopic skull base surgery was reserved for benign pathologies. Endoscopic skull base surgery is gradually gaining popularity. In spite of that, open skull base surgery is still considered the "gold standard" for the treatment of anterior skull base lesions, and it is the preferred approach in selected cases. Objective This article reviews current concepts and open approaches to the anterior skull base in children in the era of endoscopic surgery. Materials and Methods Comprehensive literature review. Results Extensive intracranial-intradural invasion, extensive orbital invasion, encasement of the optic nerve or the internal carotid artery, lateral supraorbital dural involvement and involvement of the anterior table of the frontal sinus or lateral portion of the frontal sinus precludes endoscopic surgery, and mandates open skull base surgery. The open approaches which are used most frequently for surgical resection of anterior skull base tumors are the transfacial/transmaxillary, subcranial, and subfrontal approaches. Reconstruction of anterior skull base defects is discussed in a separate article in this supplement. Discussion Although endoscopic skull base surgery in children is gaining popularity in developed countries, in many cases open surgery is still required. In addition, in developing countries, which accounts for more than 80% of the world's population, limited access to expensive equipment precludes the use of endoscopic surgery. Several open surgical approaches are still employed to resect anterior skull base lesions in the pediatric population. With this large armamentarium of surgical approaches, tailoring the most suitable approach to a specific lesion in regard to its nature, location, and extent is of utmost importance.
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Affiliation(s)
- Oshri Wasserzug
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv University, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv, Israel
| | - Ari DeRowe
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv University, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv, Israel
| | - Barak Ringel
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv University, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv, Israel
| | - Gadi Fishman
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv University, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv University, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv, Israel
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Wilson M, Snyderman C. Endoscopic Management of Developmental Anomalies of the Skull Base. J Neurol Surg B Skull Base 2018; 79:13-20. [PMID: 29404236 DOI: 10.1055/s-0037-1615815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Developmental anomalies of the skull base may present in childhood or as an adult. The most common pathologies include dermoid, encephalocele, and glioma. Encephaloceles may present as part of a syndrome. Other entities include infantile hemangiomas and teratoma. Endoscopic techniques provide a less invasive and morbid option for treatment. Proper evaluation and treatment is necessary to prevent complications such as meningitis.
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Affiliation(s)
- Meghan Wilson
- Department of Otolaryngology, Penn State Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Carl Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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