Preoperative Risk Factors Associated with Intraoperative CSF Leaks in Endoscopic Endonasal Skull Base Surgery in Children

Introduction: Endoscopic endonasal skull base surgery in children is shown to be safe and effective in several published series. However, more data are needed to evaluate risks factors for complications and outcomes in these patients.

Objective: To review perioperative risk factors for intraoperative cerebrospinal fluid (CSF) leaks and outcomes in children who have undergone endoscopic skull base surgery at our tertiary Children's hospital.

Methods: A retrospective chart review was performed on children who had undergone endoscopic endonasal skull base surgery with a two-surgeon team, a pediatric otolaryngologist and pediatric neurosurgeon between 2015 and 2020.

Result: Thirty patients (n = 30) were identified; 17 females (57%), and majority were White (13, 43%) or Hispanic (11, 37%). The average age was 12 years (range: 4–17 years), and average BMI percentile for age is 69% (range: 1–99%). The most common clinical indications for surgery were persistent headache, endocrine abnormalities, and orbital complications or change in vision. Skull base pathology included six craniopharyngiomas, five pituitary adenoma, four Rathke's cleft cyst, three germ cell tumors, three traumas, one chordoma, three congenital encephaloceles, and two patients who underwent an odontoid decompression for basilar invagination. Three patients were in an “other” category including spindle cell neoplasm in patient with history of neurofibromatosis type 1, lymphocytic hypophysitis, and granulomatous pathology concerning for Sarcoidosis. Skull base defects were repaired using materials including synthetic dural material, abdominal fat, bone or cartilage, free mucosal graft, hinged nasal mucosal graft, and nasoseptal flaps. Bone or cartilage was used in 21, and nasoseptal flaps were used in 16 patients. Sixteen (53%) patients had an intraoperative CSF leaks; 11 were high flow leaks and 5 were low flow leaks. There was no difference in gender, age, race or BMI percentile for age between the children who had an intraoperative CSF leak and those who did not. The patients who had an intraoperative CSF leak had a past medical of obesity and pathology consistent with craniopharyngioma. Twelve patients got lumbar drains – 11 were placed intraoperatively after a leak was noted or at beginning of surgery when there was a higher risk of CSF leak in pathologies such as craniopharyngioma or encephalocele. One patient had a postoperative CSF leak (3.3%).

Conclusion: Endoscopic endonasal skull base surgery performed by a pediatric neurosurgeon and otolaryngologist is a safe and effective. Obesity and craniopharyngioma are perioperative risk factors for intraoperative CSF leak. Larger studies or meta-analysis is needed for further data.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021