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The limits of endoscopic endonasal approaches in young children: a review
Andrew Kobets1, Adam Ammar2, Kamilah Dowling2
1Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe St, 5th Floor, Baltimore, MD, 21287, USA. AJKobets@gmail.com.
Insights
Endoscopic endonasal approach (EEA) is feasible in infants and children under 4 years old, even for complex conditions. Careful patient selection is crucial due to anatomical constraints in the very young.
Area of Science:
- Neurosurgery
- Otolaryngology
- Pediatric Surgery
Background:
- Endoscopic endonasal approach (EEA) offers superior visualization and instrumentation compared to microscopic techniques for deep surgical corridors.
- Existing studies on EEAs in children often lack stratification for very young patients, whose unique anatomy may pose challenges.
Purpose of the Study:
- To review the limitations and feasibility of EEAs in infants and children up to 4 years of age.
- To determine the applicability of EEA in pediatric patients with specific anatomical considerations.
Main Methods:
- A comprehensive literature review was conducted.
- Eighteen studies detailing EEAs in pediatric patients were analyzed for surgical caveats and limitations.
Main Results:
- EEAs have been successfully used in very young children for conditions including CSF leaks, meningioencephaloceles, anterior skull base tumors, and rostral cervical spine lesions.
- Despite anatomical limitations like small nares and developing sinuses, EEAs have been performed without insurmountable difficulty, even in infants as young as 6 weeks.
- Both 4-mm and 2.7-mm diameter endoscopes have been utilized, with 2.7-mm scopes favored for unilateral or bilateral approaches to preserve facial anatomy.
Conclusions:
- EEAs are a viable and beneficial surgical option for infants and young children, offering advantages like reduced blood loss and preservation of facial growth.
- While technological advancements facilitate EEA in younger patients, careful patient selection remains paramount to address anatomical constraints and ensure optimal outcomes.
- The risks and benefits of EEA versus more extensive approaches must be carefully considered for each young patient.
Introduction:
The endoscopic endonasal approach (EEA) provides visualization of four deep surgical corridors (transcribiform, transtubercular, transsellar, and transclival) with superior illumination and specialized deep-reaching instruments, as compared to microscopic techniques. Several studies have evaluated EEAs in children but do not stratify for the very young of age, whose particularly small nares and developmental anatomy may limit endonasal instrumentation.
Methodology:
A comprehensive review of EEAs in infants and children to age 4 was performed to determine the limitations in this age group.
Results:
Eighteen studies were identified describing this approach for pediatric patients and the surgical caveats and limitations were reviewed. In very small children, CSF leaks, meningioencephaloceles, tumors of the anterior skull base, and lesions at the rostral cervical spine have been successfully treated endonasally. While newer studies advocate using 2.7-mm diameter (18-cm length) lenses, 4-mm diameter rigid lenses have been used without technical difficulty. The youngest patient in whom an EEA was used was a 6-week-old for a dermoid resection. Some have advocated that due to the small nares, approaches via bilateral entry are optimal for multiple instruments, however, others, including authors of a series of 28 repaired CSF leaks demonstrate successful single nare access.
Discussion:
EEAs are associated with less blood loss, are less likely to hinder normal growth of the skull and midface, and allow for the resection of even malignant lesions. Despite the limitations of the frontal, ethmoid, and sphenoid sinuses before age 3, reports have not documented insurmountable difficulty with EEAs even in infants. 2.7-mm diameter endoscopes are favored unilaterally or bilaterally to treat both benign and malignant lesions and preserve the young patient's facial anatomy better than older methods. Ever improving technology has facilitated the use of this approach in patients it would otherwise be infeasible for in the past, but it still cannot overcome the anatomical constraints of certain young patients in which this approach remains unindicated. Patient selection is therefore of utmost importance and the risks and benefits of more extensive approaches in these cases must be considered.
