Reconstruction of Pediatric Skull Base Defects: A Retrospective Analysis Emphasizing the Very Young

Background: 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 anatomical 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. Fifty-five patients were identified and charts were reviewed with particular attention paid to reconstructive techniques utilized, postoperative outcomes, and complications.

Results: Intraoperative CSF leak was noted in 50% (3/6) of the patients ≤6 years of age compared with 32.7% (16/49) in patients >6 years of age and ≤20 years of age (p < 0.40). A vascularized flap was utilized for reconstruction in 66.7% (4/6) of the patients ≤6 years of age and most commonly included a nasoseptal flap in 33.3% (2/6). A vascularized flap was utilized for reconstruction in 38.8% (19/49) of the patients >6 years of age and ≤20 years of age and most commonly included a nasoseptal flap (22.4%, 11/49; p < 0.50). Absorbable packing was utilized to support the reconstruction in 83.3% (five of six) patients ≤6 years of age and 79.6% (39/49) patients >6 years of age and ≤20 years of age. Merocel nonabsorbable packing was used in 50% (three of six) of the patients ≤6 years of age. Nonabsorbable packing was utilized in 44.9% (22/49) of the patients >6 and ≤20 years of age and included merocel (30.6%, 15/49) or Foley’s catheter (12.2%, 6/49; p < 0.68). A lumbar drain was utilized in 50% (three of six) of the patients ≤6 years of age compared with 18.4% (9/49) in patients >6 and ≤20 years of age (p < 0.08). Postoperative CSF leak was found in 16.7% (one of six) of patients ≤6 years of age compared with 10.2% (5/49) in patients >6 and ≤20 years of age (p < 0.63). Behavioral issues were noted to contribute to failed skull base reconstruction in patients <6 years of age. There were no cases of new cranial nerve injury in patients ≤6 years of age and two instances in patients >6 years of age and ≤20 years of age (p < 0.65). A similar rate of persistent or recurrent disease was noted between both groups (p < 0.39 and 0.98, respectively). The median length of stay was 7.5 days in patients ≤6 years of age and 4.0 days in patients >6 and ≤20 years of age (p < 0.44).

Conclusion: Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomical and behavioral challenges for the skull base surgeon as highlighted in this study.