Lack of Sphenoid Pneumatization Does Not Affect Endoscopic Endonasal Pediatric Skull Base Surgery Outcomes Edward C. Kuan, MD, MBA; Adam C. Kaufman, MD, PhD; David Lerner, MD; Michael A. Kohanski, MD, PhD; Charles C. L. Tong, MD; Bobby A. Tajudeen, MD; Arjun K. Parasher, MD; John Y. K. Lee, MD; Phillip B. Storm, MD; James N. Palmer, MD; Nithin D. Adappa, MD Objectives/Hypothesis: Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediat- ric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/ transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns. Study Design: Retrospective chart review. Methods: A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center. Results: A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total opera- tive time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959). Conclusions: Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase com- plications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes. Key Words: Skull base surgery, outcomes, sphenoid, sella, cerebrospinal fluid leak, craniopharyngioma. Level of Evidence: 4 Laryngoscope, 129:832–836, 2019 INTRODUCTION Pediatric skull base tumors are a rare entity, repre- senting only 5% to 6% of all skull base tumors. 1 The most common benign pathologies include craniopharyngiomas, nerve sheath tumors, and juvenile nasopharyneal angiofibroma, whereas the most prevalent malignant pathologies include chondrosarcoma, chordoma, and rhab- domyosarcoma. 1,2 Typically, treatment of pediatric skull base tumors is accomplished via surgical resection, histor- ically carried out through an open approach. More recently, the expanded endoscopic approach (EEA) has gained in favor due to improved endoscopic techniques and the benefits of minimizing several potential morbid- ities associated with open procedures. 1–3 Serious intrao- perative complications of EEA to the skull base are rare, but can involve damage to critical neurovascular struc- tures including the internal carotid artery, optic nerves or chiasm, or other cranial nerves. 3,4 A unique aspect of applying EEA to pediatric skull base tumors is the variable degree of sphenoid sinus devel- opment. The sphenoid sinus is often filled with solid bone at birth, but begins the process of pneumatization as early as 4 months of age (generally around age 3 years) but does not reach maturity until approximately age 10 to 14 years. 4–7 An incompletely pneumatized sphenoid sinus necessitates drilling of the sphenoid bone to access the sella and parasellar region, decreasing working room and poten- tially increasing operative time. 4,8 Additionally, a poorly developed sinus precludes intraoperative visualization of bony landmarks (i.e., opticocarotid recess) for locating cru- cial neurovascular structures. 3,8–10 This has led many to From the Department of Otolaryngology–Head and Neck Surgery (E.C.K.), University of California, Irvine Medical Center, Orange, California; Department of Otorhinolaryngology–Head and Neck Surgery (A.C.K., D.L., M.A.K., C.C.L.T., J.N.P., N.D.A.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Otolaryngology–Head and Neck Surgery (B.A.T.), Rush University Medical Center, Chicago, Illinois; Department of Otolaryngology–Head and Neck Surgery (A.K.P.), University of South Florida, Tampa, Florida; Department of Neurosurgery (J.Y.K.L.), University of Pennsylvania, Philadelphia, Pennsylvania; and the Division of Neurosurgery (P.B.S.), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A. Editor’s Note: This Manuscript was accepted for publication on September 12, 2018. Presented as a poster at the 2018 American Rhinologic Society Meeting, Combined Otolaryngological Society Meetings, National Harbor, Maryland, U.S.A., April 18–22, 2018. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Nithin D. Adappa, MD, Division of Rhinol- ogy and Skull Base Surgery, Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Ravdin 5, Philadelphia, PA 19104. E-mail: nithin. adappa@uphs.upenn.edu DOI: 10.1002/lary.27600 Laryngoscope 129: April 2019 Kuan et al.: Sphenoid Pneumatization Skull Base Outcomes 832 The Laryngoscope © 2018 The American Laryngological, Rhinological and Otological Society, Inc.