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Corridor-Based Endonasal Endoscopic Surgery for Pediatric Skull Base Pathology With Detailed Radioanatomic Measurements

Banu, Matei A. MD*; Rathman, Allison DO*; Patel, Kunal S. BS*; Souweidane, Mark M. MD*,‡; Anand, Vijay K. MD§; Greenfield, Jeffrey P. MD, PhD*,‡; Schwartz, Theodore H. MD*,§,‖

doi: 10.1227/NEU.0000000000000252
Surgical Anatomy and Technique

BACKGROUND: Pediatric anatomy is more restricted, and the propagation of endonasal endoscopic approaches in the pediatric population has been limited.

OBJECTIVE: To demonstrate the feasibility of the endonasal endoscopic approach in a variety of age groups and to perform measurements of the corridors and spaces available for surgery as a guide for case selection.

METHODS: Only patients <18 years were included. The choice of operative corridor/approach is described in relation to pathological entity and location. Preoperative/postoperative visual fields and endocrine panels, extent of resection, as well as postoperative long-term complications are described. Prospective magnetic resonance image-based anatomic measurements of key distances were performed to determine age-dependent surgical indications and limitations.

RESULTS: Forty purely endoscopic procedures were performed in 33 pediatric patients (5-18 years of age) harboring a variety of skull base lesions, from benign tumors to congenital malformations. For the 20 patients in whom gross total resection was the intended goal of surgery, gross total resection was attained in 15 (75%). There were 2 infections (5%) and no cerebrospinal fluid leaks. Significant improvement was shown in 58.3% of patients with visual deficits. Hormone overproduction resolved in 75% of patients, while preoperative hormone insufficiency only improved in 29.2%. Wider intercarotid distance at the superior clivus (P = .01) and shorter nare-dens working distance (P = .001) predicted improved outcomes and fewer postoperative complications.

CONCLUSION: Endonasal endoscopic skull base approaches are viable in the pediatric population, they are not impeded by sphenoid sinus aeration, and they have minimal risk of cerebrospinal fluid leak and meningitis. Outcomes and complications can be predicted based on specific radio anatomical skull base measurements rather than age.

ABBREVIATIONS: ASB, anterior sphenoid bone

ASW, anterior sellar wall

DI, diabetes insipidus

EEA, endonasal endoscopic approach

FSE, fast spin echo

GH, growth hormone

GTR, gross total resection

ICD-CS, intercarotid distance at the level of the cavernous sinus

ICD-SC, intercarotid distance at the superior clivus

MaxWiT, maximum width between middle turbinates

NDD, nare-dens distance

NSD, nare-sellar distance

NVD, nare-vomer distance

SKB, skull base

STR, subtotal resection

TA, transsphenoidal angle

VCD, vomer-clival distance

*Department of Neurological Surgery, Weill Cornell Medical College, New York, New York;

Department of Pediatrics, Weill Cornell Medical College, New York, New York;

§Department of Otolaryngology, Head and Neck Surgery, Weill Cornell Medical College, New York, New York;

Department of Neurology and Neuroscience, Brain and Spine Center, Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York

Correspondence: Jeffrey P. Greenfield, MD, PhD, 525 East 68th St, Box 99, New York, NY 10065. E-mail:

Received June 12, 2013

Accepted November 11, 2013

Copyright © by the Congress of Neurological Surgeons