The Utility of a “Second-Look” Debridement Following Endonasal Skull Base Surgery in the Pediatric Population

Michael T. Chang; Alice E. Huang; Jennifer L. Quon; Juan C. Fernandez-Miranda; Christopher Z. Wen; Jacob G. Eide; Rijul S. Kshirsagar; Z Jason Qian; Jayakar V. Nayak; Peter H. Hwang; Nithin D. Adappa; Zara M. Patel

doi:10.1055/a-2048-7564

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2024; 85(03): 313-317
DOI: 10.1055/a-2048-7564

Original Article

The Utility of a “Second-Look” Debridement Following Endonasal Skull Base Surgery in the Pediatric Population

Michael T. Chang

¹Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States

,

Alice E. Huang

¹Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States

,

Jennifer L. Quon

²Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States

,

Juan C. Fernandez-Miranda

²Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States

,

Christopher Z. Wen

³Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States

,

Jacob G. Eide

³Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States

,

Rijul S. Kshirsagar

³Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States

,

Z Jason Qian

¹Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States

,

Jayakar V. Nayak

¹Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States

,

Peter H. Hwang

¹Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States

,

Nithin D. Adappa

³Department of Otorhinolaryngology – Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States

,

Zara M. Patel

¹Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States

› Author Affiliations

Abstract

Background Sinonasal debridement is typically performed in the weeks following endonasal skull base surgery (ESBS). In the pediatric population, this second-look procedure may require general anesthesia; however, there is currently little evidence assessing the benefit of this practice.

Methods This was a multicenter retrospective study of pediatric patients (age <18 years) undergoing a planned second-look debridement under general anesthesia following ESBS. Intraoperative findings, interventions performed, and perioperative complications were reviewed. Multivariate regression analysis was performed to identify associations between intraoperative findings and clinical factors.

Results We reviewed 69 cases of second-look debridements (age mean 8.6 ± 4.2 years, range: 2–18 years), occurring a mean of 18.3 ± 10.3 days following ESBS. All abnormal findings were noted in patients age ≤12 years. Synechiae were noted in 8.7% of cases, bacterial rhinosinusitis in 2.9%, and failed reconstruction with cerebrospinal fluid leak in 4.5% (two cases of flap malposition and one case of flap necrosis). All failed reconstructions were noted following expanded endonasal cases for craniopharyngioma, and in each case, a revision reconstruction was performed during the second-look surgery. Synechiae were not significantly associated with younger age, revision cases, or cases with reconstructive flaps. There were no perioperative complications.

Conclusion Second-look debridement under general anesthesia may be useful in the identification and intervention of sinonasal pathology following endoscopic skull base surgery, particularly in children ≤12 years old or those with pedicled flap reconstructions. Larger controlled studies are warranted to validate this practice and refine indications and timing of this second procedure.

Keywords

skull base - endoscopic - quality of life - sinonasal outcomes - postoperative care

Full Text

References

References
1 London Jr NR, Rangel GG, Walz PC. The expanded endonasal approach in pediatric skull base surgery: A review. Laryngoscope Investig Otolaryngol 2020; 5 (02) 313-325
2 Helmen ZM, Little RE, Robey T. Utility of second-look endoscopy with debridement after pediatric functional endoscopic sinus surgery in patients with cystic fibrosis. Ann Otol Rhinol Laryngol 2020; 129 (12) 1153-1162
3 Mitchell RB, Pereira KD, Younis RT, Lazar RH. Pediatric functional endoscopic sinus surgery: is a second look necessary?. Laryngoscope 1997; 107 (09) 1267-1269
4 Brietzke SE, Shin JJ, Choi S. et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg 2014; 151 (04) 542-553
5 Stapleton AL, Tyler-Kabara EC, Gardner PA, Snyderman CH. The costs of skull base surgery in the pediatric population. J Neurol Surg B Skull Base 2015; 76 (01) 39-42
6 Chabot JD, Patel CR, Hughes MA. et al. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2018; 128 (05) 1463-1472
7 Awad AJ, Mohyeldin A, El-Sayed IH, Aghi MK. Sinonasal morbidity following endoscopic endonasal skull base surgery. Clin Neurol Neurosurg 2015; 130: 162-167
8 de Almeida JR, Snyderman CH, Gardner PA, Carrau RL, Vescan AD. Nasal morbidity following endoscopic skull base surgery: a prospective cohort study. Head Neck 2011; 33 (04) 547-551
9 Gallagher MJ, Durnford AJ, Wahab SS, Nair S, Rokade A, Mathad N. Patient-reported nasal morbidity following endoscopic endonasal skull base surgery. Br J Neurosurg 2014; 28 (05) 622-625
10 Pant H, Bhatki AM, Snyderman CH. et al. Quality of life following endonasal skull base surgery. Skull Base 2010; 20 (01) 35-40
11 Green R, Banigo A, Hathorn I. Postoperative nasal debridement following functional endoscopic sinus surgery, a systematic review of the literature. Clin Otolaryngol 2015; 40 (01) 2-8
12 Nilssen EL, Wardrop P, El-Hakim H, White PS, Gardiner Q, Ogston S. A randomized control trial of post-operative care following endoscopic sinus surgery: debridement versus no debridement. J Laryngol Otol 2002; 116 (02) 108-111
13 Alsaffar H, Sowerby L, Rotenberg BW. Postoperative nasal debridement after endoscopic sinus surgery: a randomized controlled trial. Ann Otol Rhinol Laryngol 2013; 122 (10) 642-647
14 Bugten V, Nordgård S, Steinsvåg S. Long-term effects of postoperative measures after sinus surgery. Eur Arch Otorhinolaryngol 2008; 265 (05) 531-537
15 Bugten V, Nordgård S, Steinsvåg S. The effects of debridement after endoscopic sinus surgery. Laryngoscope 2006; 116 (11) 2037-2043
16 Tzelnick S, Alkan U, Leshno M, Hwang P, Soudry E. Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery. Cochrane Database Syst Rev 2018; 11 (11) CD011988