Approaching the Sella through the Nonpneumatized Sphenoid in Pediatric Patients

Abstract

Objective The purpose of this study is to specifically assess pediatric patients with nonpneumatized sphenoid sinuses who have undergone transsphenoidal resections of skull base tumors and assess the complications and outcomes. Methods Data was collected by a retrospective chart review done on children ages 7 and under who underwent endoscopic tumor resection and had a partially or completely nonpneumatized sphenoid sinus on preoperative computed tomography imaging. Surgical data collected included surgical corridor, gross total versus subtotal resection, repair method, use of septal flap, intraoperative and postoperative cerebrospinal fluid leak, and estimated blood loss. Results Six patients were identified that fit our inclusion criteria who underwent surgery between November 2015 and April 2018 (3 males, 3 females; average age = 4.28 years). Tumor pathologies include three craniopharyngiomas, Rathke cleft cyst, meningocele, and neuroblastoma. All cases involved varying percentages of sphenoid sinus pneumatization. All cases except one craniopharyngioma and the neuroblastoma required removal of cancellous bone to access pathology. Degree of sphenoid pneumatization tended to be greater with age and resulted in less intraoperative bleeding. The two youngest patients with completely nonpneumatized sphenoid sinuses lost 61.73 and 17.52% of their total blood volume intraoperatively. Procedures were able to be adequately performed and pathology completely addressed with minimal postoperative complications and no postoperative CSF leaks. Conclusions Intraoperative challenges including hemorrhage are likely in nonpneumatized patients, and thus surgeons should be prepared with adequate vascular access and blood products. Hemorrhage and total blood volume loss are increased in the younger patients with no sphenoid pneumatization. Despite the additional challenges, a nonpneumatized sphenoid sinus is not a contraindication for an endoscopic resection in the pediatric population.

Keywords: endoscopic tumor resection; nonpneumatized sphenoid sinus; skull base tumor; transsphendoidal resection.

Fig. 1

Preoperative sagittal computed tomography images. ( A ) The completely nonpneumatized sphenoid sinus of a 13-month-old patient with a Rathke cleft cyst. ( B ) A partially pneumatized sphenoid sinus, ∼70%, in a 7-year-old patient with a sellar craniopharyngioma.

Fig. 2

Intraoperative endoscope images. ( A ) The anterior sphenoid wall with cancellous bone in the center at the site of the future sphenoid ostia, and the cortical bone of the anterior sphenoid wall to the left. ( B ) The brownish Rathke cleft cyst seen at region of sella turcica identifying posterior extent of sphenoid removal.