Indications and Limits of Endoscopic Endonasal Approaches in Pediatric Neurosurgery

Endoscopic endonasal approaches (EEAs) are a safe and effective method for treating skull base lesions, including those in the sellar and parasellar areas. Pioneered initially for the treatment of skull base pathology in adults, these approaches have shown clear advantages including cost-effectiveness, limited blood loss, and improved visualization allowing for a better plane of dissection and clearing anatomical landmarks. However, in younger patients, this approach could be limited due to their developing anatomy, small anatomical corridors, or peculiarities of specific lesions which could not be amenable for a simple approach.The width of the piriform aperture, sphenoid bone pneumatization, and intercarotid distances at different coronal planes should all be considered during preoperative evaluation of pediatric patients for EEAs. EEAs below the age of 2 years at parasellar ICA level and below 4 years at paraclinoid ICA level should deserve particular attention. As children grow, the progressive pneumatization of paranasal sinuses expands the anatomy of these corridors and it is generally assumed that anatomical factors would not restrict an endoscopic transsphenoidal approach in children older than 5 years of age.The pediatric population offers unique challenges because of the smaller working spaces and the smaller size of the skull base involved.