Operative Techniques in Otolaryngology-Head and Neck Surgery

Locoregional flaps in pediatric anterior skull base surgery Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Christopher Pool, Neerav Goyal, Jessyka G. Lighthall Management of skull base defects involves the separation of the cranial cavity from the nasal cavity in order to prevent cerebrospinal fluid leak, pneumocephalus, and intracranial infection. The size and location of the defect as well as donor tissue available will determine the type of reconstruction. Reconstruction options include free tissue grafts, locoregional flaps, and microvascular free flaps. In children, the size of potential flaps must be considered as well as the length of the pedicle, as often these differ in children. This article will discuss numerous reconstructive options, focusing on locoregional flaps in skull base reconstruction. In addition to outlining the surgical technique for each type, we will review considerations in pediatric patients for each reconstructive option.

Special considerations for nasoseptal flap use in children Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Edward C. Kuan, Ryan M. Carey, James N. Palmer, Nithin D. Adappa The introduction of the vascularized pedicled nasoseptal flap has revolutionized endoscopic skull base surgery, providing a highly versatile option to repair even the most complex skull base defects. Though demonstrated with outstanding results in adult patients, there is limited experience in the pediatric population. Early investigation found that there are limitations in utilization of the nasoseptal flap in children due to craniofacial restrictions. More recently, these concerns have been mitigated, and nasoseptal flaps are reliably used in reconstructing even the largest skull base defects in the youngest patients. Preoperative planning and review of imaging and meticulous intraoperative dissection are essential for successful reconstructive outcomes.

Open anterior skull base surgery in the pediatric population: anatomy, approaches, and considerations Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Tristan Tham, Peter Costantino The objectives of this paper are to synthesize the existing literature on open approaches to the anterior skull base in children. First, we review the developmental anatomy of the anterior skull base. Next, we describe the most commonly used open approaches to the anterior skull base and other adjunctive procedures. Lastly, we review the reconstructive options and comment important pediatric-specific considerations. Our review reports the variety of open approaches to access the anterior skull base in children. Detailed preoperative planning, taking age-related considerations into account, is necessary in order to plan to type and extent of access and reconstruction.

Surgical management of clival chordomas in children Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Carl H. Snyderman, Paul A. Gardner, Elizabeth C. Tyler-Kabara Objective: Describe the surgical management of clival chordomas in the pediatric population, with an emphasis on techniques of endoscopic endonasal surgery. Finding: Endoscopic endonasal approaches to the clivus provide access from posterior clinoids to foramen magnum. The clivus is divided into thirds (superior, middle, and inferior), each with corresponding vascular and neural structures. The abducens nerve is at greatest risk for injury due to spread of tumor within the interdural space to Dorello's canal. Despite decreased pneumatization of the sinuses in pediatric patients, the same techniques can be applied to this population. The contralateral transmaxillary approach enhances the ability to achieve a gross total resection when tumor extends laterally into the petrous apex. A multi-layer reconstruction with vascularized tissue minimizes the risk of cerebrospinal fluid leak. Conclusion: Endoscopic endonasal surgery can be safely applied to the pediatric population and provides the best opportunity for complete surgical excision for most tumors.

Treatment of fibro-osseous lesions at the pediatric skull base Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Jeffrey C. Rastatter, Jeffrey Leonard, Patrick C. Walz Fibro-osseous lesions of the pediatric skull base are loosely associated group of bony lesions that are all uncommonly occurring clinical entities. Management differs significantly amongst the fibro-osseous lesions but clinical and radiographic presentation can overlap significantly. Fibro-osseous lesions include fibrous dysplasia, ossifying fibroma, osteoma, and aneurysmal bone cyst in addition to even less common lesions such as giant cell tumor of bone and osteosarcoma. In this chapter, the fibro-osseous lesions affecting the pediatric skull base will be reviewed with an emphasis on the clinical, radiographic, and management differences between diagnoses.

The endoscopic endonasal approach for pediatric craniopharyngiomas Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Ian J. Koszewski, Hermes G. Garcia, William Parkes, Chandala Chitguppi, Mindy R. Rabinowitz, Gurston G. Nyquist, James J. Evans, Marc R. Rosen Craniopharyngiomas are rare but challenging tumors of the ventral skull base affecting primarily pediatric patients. In select cases, the endoscopic endonasal approach represents an appropriate surgical option when tumor resection is favored. However, nuances of the pediatric nasal corridor must be carefully considered to optimize both tumor resection and skull base reconstruction. Here we review pertinent developmental details, options for creation of an optimal endonasal corridor, principles of tumor resection, and techniques for reconstruction. Considerations for intraoperative and postoperative patient care are also reviewed.

Endoscopic transsphenoidal pituitary surgery in children Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Edward C. Kuan, Phillip B. Storm, James N. Palmer, Nithin D. Adappa With increasing adoption of endoscopic techniques and improved knowledge of skull base anatomy and approaches, transsphenoidal pituitary surgery is now being performed on patients of all ages. Surgical principles are similar between pediatric and adult patients, but there are special considerations for the pediatric population in terms of instrumentation, surgical anatomy, and postoperative care. Wide exposure to the sella, oftentimes to accommodate multiple instruments and the endoscope, is frequently necessary. Persistent collaboration among the otolaryngology, neurosurgery, and anesthesiology teams is of critical importance to ensure optimal outcomes.

Pediatric skull base surgery: Encephaloceles and cerebrospinal fluid leaks Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Jacob G. Eide, Patrick Walz, Tord D. Alden, Jeffrey C. Rastatter In recent years, endoscopic endonasal approaches to the pediatric skull base have become an increasingly popular method for treatment of a variety of malignant and benign lesions. These approaches have largely evolved from experience in adult patients and can be an excellent alternative to open procedures in carefully selected patients. Pediatric encephaloceles can be addressed via open craniotomy, transpalatal, and endoscopic endonasal methods. The surgical approach should be dictated by the anatomy of the patient as well as the size and location of the encephalocele in question. Pediatric cerebrospinal fluid leaks can occur due to iatrogenic causes during skull base resections or sinus surgery, as well as from traumatic injury. Multiple options for repair of cerebrospinal fluid leaks exist, but endoscopic nasoseptal flaps are among the most commonly utilized reconstruction options.

Surgical management of juvenile nasopharyngeal angiofibroma Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Meghan N. Wilson, Daniel W. Nuss, Brad E. Zacharia, Carl H. Snyderman Juvenile nasopharyngeal angiofibromas are benign yet aggressive anterior skull base tumors that occur almost exclusively in male adolescents. Diagnosis is typically made through radiographic findings and clinical characteristics; biopsy is not recommended due to the vascular nature of the disease. As with most tumors, there is a spectrum of tumor extent and invasion. In juvenile nasopharyngeal angiofibromas, one of the most important components of extent is the vascular supply. Once the vascular supply is identified, a systematic approach to resection can be planned. The majority of these tumors can be excised endoscopically, and those approaches are the focus of this article.

Surgical management of nasal dermoid lesions Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Craig Miller, Scott Manning, Randall Bly Nasal dermoids are the most common congenital midline nasal lesions. They often present as a midline pit or nasal mass and arise from incomplete or failed regression of the dural diverticulum during embryogenesis. Management requires complete resection of the tract and an appropriate surgical approach is based on location, extent, and presence and/or degree of intracranial extension. Classically requiring an open craniotomy for resection, newer strategies employ a minimally disruptive approach to fully excise the lesion and the tract to prevent recurrence. This article presents details on embryology, imaging work up, and surgical technique for resection of these lesions either via an open approach or with an endoscopic-assisted method.

Alexandros Sfakianakis
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