Endoscopic Endonasal Approach for Skull Base Lesions in the Pediatric Population

Introduction: The endoscopic endonasal approach (EEA) has been widely accepted as a safe and effective approach for skull base lesions in the adult population, but has only recently started gaining popularity in the pediatric population due to concerns regarding anatomical constraints. We sought to examine the largest single institution cohort of EEA for skull base lesions in children in order to characterize its utility and complication profile.

Methods: We conducted a retrospective review of all pediatric patients who received neurosurgery using an endoscopic endonasal approach for a skull base pathology at a single institution from 2004 to 2024. Demographic, histopathologic, molecular, and clinical information were collected. Aggregate data were compiled and analyzed for trends in outcomes.

Results: We identified 133 cases using endoscopic endonasal approach in 103 patients. Twenty-one patients underwent more than one EEA procedure. Median age was 14.3 years old. Tumor resection was the most common indication (n = 87, 65.4%), followed by biopsy (n = 18, 13.5%), and CSF fistula or skull base defect repair (n = 11, 8.3%), with 7.5% of cases (n = 10) being some combination of the above. Craniopharyngioma was the most common pathology (n = 45, 33.8%), followed by pituitary adenoma (n = 28, 21%), Rathke’s cleft cyst (n = 11, 8.3%), CSF fistula (n = 9, 6.8%), germinoma (n = 7), chordoma (n = 6, 5.3%), and nasal dermoid cyst (n = 5, 3.8%). Various other rare pathologies made up 16.5% of our cohort (n = 22). Fat grafts were used in 47.7% of cases. Nasoseptal flaps were employed in 36.8% of cases (n = 49) and pericranial flaps in 2.2% (n = 3). DI was the most common complication occurring in 18% of cases (n = 24), followed by CSF leak (n = 19, 14.3%), and other pituitary dysfunction (n = 9, 6.8%). Median length of ICU stay was 1 day (range: 0–23), and median total length of stay was 4 days (range: 1–47).

Conclusion: In our cohort, pediatric EEA carried a similar risk profile of CSF leak to EEA cases in adults, with a higher rate than open cases in the literature. Rates of DI in our cohort were on the lower end of rates reported elsewhere. Prophylactic fat graft use was higher in our population than that reported in the adult population, while nasoseptal flap usage was similar. Patients undergoing EEA had comparable ICU and total length of hospital stays to those reported for open craniotomies. EEA is a safe and effective approach in the pediatric population and can be used for a variety of applications. Comparable outcomes to the adult population support broader use of EEA in pediatric neurosurgery.

Publication History

Article published online:
07 February 2025