Introduction: Transnasal endoscopic transphenoidal approaches are an essential technique for the resection of skull base tumors in adults. Originally devised and most commonly used to treat pituitary adenomas, they have also been used for a variety of other pathologies. However, in the pediatric population, sellar and suprasellar lesions have historically involved a craniotomy. Transnasal endoscopic transphenoidal techniques in children have only been reported as single case reports and only in regard to purely sellar lesions.
Methods: We present the first reported series of transnasal endoscopic transphenoidal approaches for pediatric skull base tumors. We performed a retrospective review of pediatric patients at our institution who had undergone endoscopic transphenoidal approaches for either a biopsy or resection of their sellar or suprasellar lesions between 2000 and 2015.
Results: Our series included 29 patients with ages ranging between 4 and 17-years old. Headache (59%), visual changes (55%), and diabetes insipidus (34%) were the predominant presenting symptoms. Twenty-six patients (90%) noted some improvement in their symptoms post-operatively.
The majority of patients had secreting pituitary adenomas (38%) followed by Rathke cleft cysts/craniopharyngiomas (31%) and germinomas (13%). Other pathologies included lymphocytic hypophysitis, mature teratoma, and clival chordoma. Patients primarily underwent gross total resections (56%) with a low rate (27.5%) of reresection. Only two cases (7%) necessitated a subsequent craniotomy for tumor regrowth into anatomically challenging areas. Eleven (30%) patients had septal flaps, 17(46%) had fat grafts, and 13(45%) had intraoperative placement of a lumbar drain. Two patients (7%) had post-operative CSF leak. The majority of patients (79%) required hormonal supplementation following resection, with fewer requiring subsequent chemotherapy (24%) and radiation (24%).
Conclusions: Transnasal endoscopic transphenoidal approaches are preferable to craniotomy and are safe and effective for accessing sellar, suprasellar and parasellar lesions in children. Further refinement in technology will allow for more widespread use in the pediatric population.
Patient Care: Our series advocates for a less invasive but highly effective approach for anatomically difficult tumors in the pediatric population
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Understand our institutional experience with transnasal endoscopic transphenoidal approaches in children
2) Describe the optimal settings in which to use this technique
3) Discuss possibilities for improving and expanding the use of transnasal endoscopic approaches in children
References: 1. Ceylan S, Koc K, Anik I: Extended endoscopic approaches for midline skull-base lesions. Neurosurg Rev 32:309-319; discussion 318-309, 2009
2. Das K, Spencer W, Nwagwu CI, Schaeffer S, Wenk E, Weiss MH, et al: Approaches to the sellar and parasellar region: anatomic comparison of endonasal-transsphenoidal, sublabial-transsphenoidal, and transethmoidal approaches. Neurol Res 23:51-54, 2001
3. Gaillard S: The transition from microscopic to endoscopic transsphenoidal surgery in high-caseload neurosurgical centers: the experience of Foch Hospital. World Neurosurg 82:S116-120, 2014