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Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.

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The work illustrates a step-by-step surgical approach to demonstrate technical feasibility of a single-stage endoscopic repair for bilateral choanal atresia with adjuvant bioabsorbable steroid-eluting stent placement to safely mitigate unique perioperative challenges in the pediatric population. Laryngoscope, 134:4414-4417, 2024.

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BACKGROUND AND IMPORTANCE: Basal encephaloceles are the result of a concomitant cranial and dural defect that allows for inferior displacement of cerebral tissue, meninges, and cerebrospinal fluid into the paranasal sinuses and outside the cranial vault. This work illustrates a step-by-step surgical approach of a successful single-stage, endoscopic repair of a congenital basal encephalocele in a 10-year-old child, using a free mucosal middle turbinate graft that provided effective results without utilization of traditional open reconstructive techniques or vascularized flaps. CLINICAL PRESENTATION: A previously healthy 10-year-old male with a history of unilateral clear rhinorrhea was admitted as an inpatient because of an acute episode of nausea, vomiting, and confusion, accompanied by fever, diplopia, and bilateral abducens nerve palsies. Preoperative imaging revealed a 2-cm right-sided intranasal mass accompanied by a subcentimeter skull base defect spanning the lateral lamella. After completing a course of intravenous antibiotic therapy for 1 week after a negative lumbar puncture to ensure clearance of intracranial infection, the decision was made to proceed with definitive endoscopic skull base repair to obviate recurrent bacterial meningitis episodes and potential neurological complications. CONCLUSION: This study demonstrates technical feasibility of a single-stage endoscopic endonasal approach for pediatric basal encephalocele resection and repair which minimizes craniofacial morbidity associated with traditional open approaches and sinonasal morbidity associated with local pedicle-based flaps for small cranial base defects in this unique patient population.

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Air guns, particularly BB (ball-bearing or bullet ball) guns, have gained significant power and velocity over the last few decades. More than 145,000 pediatric patients suffered injuries attributed to air guns in the United States between 2001 and 2011, and approximately 22,000 pediatric emergency department visits are attributed to air gun-related injuries annually (Hyak et al., 2020 [1]). This study aims to describe an effective surgical technique in addressing maxillofacial injuries caused by BB gun projectiles in the pediatric population. We present a detailed surgical approach for endoscopic endonasal retrieval of a transorbital projectile in a 13-year-old male who sustained a maxillofacial BB gun injury, with the goal of restoring sinonasal function in a minimally invasive fashion.

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Background: Spontaneous cerebrospinal fluid (CSF) rhinorrhea in the pediatric population is an exceedingly rare condition that occurs when the dura mater is breached, resulting in CSF drainage from the subarachnoid space into surrounding sinonasal tissue. Objective: This work delineates a step-by-step surgical approach to visually demonstrate the feasibility of an uninarial endoscopic endonasal approach for pediatric spontaneous CSF leak repair. Postoperative Outcome: A 2-year-old male with a 6-month history of clear rhinorrhea, intermittent headaches, and a previous episode of bacterial meningitis was evaluated as an inpatient consultation. Computed tomography cisternography revealed active CSF extravasation at the right sphenoid sinus roof. An endoscopic endonasal approach was performed including a complete sphenoethmoidectomy plus middle turbinectomy to provide access to the skull base defect. Once identified, a middle turbinate free mucosal graft was placed for cranial base reconstruction given the child's young agre. Sinonasal debridement 3 weeks following surgery under anesthesia revealed an intact viable graft with no evidence of CSF leak. There was no evidence of CSF leak recurrence or complications 1 year following surgery. Conclusion: The uninarial endoscopic endonasal approach is a safe and effective option for the surgical management of spontaneous CSF leak rhinorrhea in the pediatric population.

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CASE PRESENTATION: A 72-year-old woman presented to our institution with gradually worsening shortness of breath and bilateral lower extremity edema of 3 weeks' duration. She had associated complaints of cough and intermittent hemoptysis. Her medical history was significant for hypertension and hypothyroidism. She was a former cigarette smoker with a 35 pack-year smoking history. She had no recent travel history and had a pet dog at home. Six months before the current hospitalization, evaluation for cough had revealed mediastinal lymphadenopathy at an outside institution. She underwent evaluation with an endobrachial ultrasound procedure at an outside facility 8 weeks before the current admission. The procedure demonstrated both acute and chronic inflammation, with one specimen showing few atypical cells on cytopathology and no growth on bacterial, fungal, and mycobacterial cultures. She was treated empirically with oral steroids for presumed sarcoidosis. However, this did not result in clinical benefit, and because of progressive symptoms, she presented to our institution.

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ABSTRACT: Despite cleft lip repair having demonstrated safety when performed in the outpatient setting, patients with comorbidities are significantly more likely to be hospitalized overnight. There are several comorbidities overrepresented with inpatient admission, but only cardiac risk has any association with adverse outcomes in premature patients. The severity of cardiac risk is significantly associated with adverse events at all degrees of prematurity (P all ≤0.002). In premature patients with major cardiac risk factors, adverse events are significantly associated with younger age (P = 0.016) and lower weight (P = 0.013). Performing cleft lip repair on children older than 125 days (P < 0.001, before cutoff: 50.0% vs after cutoff: 6.4%) and weight greater than 10 lbs (P < 0.001, before cutoff: 56.4% vs after cutoff: 6.1%) provides a significant reduction in postoperative adverse events in premature patients with major cardiac risk factors.

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ABSTRACT: Nasal dermoid cysts represent a spectrum of complexity from dermal sacs to multiloculated sinus tracts with intracranial extension with treatments ranging from outpatient excision to transcranial procedures involving dissection of the dermoid from the dura mater. In this study, the authors examined national outcomes across the spectrum utilizing the NSQIP database. Interestingly, complication rates were uniformly low at 1.2% even though those requiring transcranial excision required significantly longer surgical procedures (P = 0.001), and were significantly more likely to be admitted as inpatients (P < 0.001). Risk factors for longer surgery included patients with comorbidities (P = 0.006), patients requiring rhinoplasty (P = 0.001), and patients requiring a craniotomy (P = 0.023). While uncommon (0.3%), infectious complications remain primary drivers of postoperative morbidity. The NSQIP database does not allow for calculation of recurrence risk, likely a driver of poorer long-term outcomes, and efforts to quantify recurrence risk will be the subject of future research.

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BACKGROUND: The global COVID-19 pandemic has had a profound impact on facial plastic and reconstructive surgery. Our review serves as a safety resource based on the current literature and is aimed at providing best-practice recommendations. Specifically, this article is focused on considerations in the management of craniomaxillofacial trauma as well as reconstructive procedures after head and neck oncologic resection. METHODS: Relevant clinical data were obtained from peer-reviewed journal articles, task force recommendations, and published guidelines from multiple medical organizations utilizing data sources including PubMed, Google Scholar, MEDLINE, and Google search queries. Relevant publications were utilized to develop practice guidelines and recommendations. CONCLUSIONS: The global COVID-19 pandemic has placed a significant strain on health care resources with resultant impacts on patient care. Surgeons operating in the head and neck are particularly at risk of occupational COVID-19 exposure during diagnostic and therapeutic procedures and must therefore be cognizant of protocols in place to mitigate exposure risk and optimize patient care.

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BACKGROUND: The direct costs associated with different diagnostic algorithms to localize cerebrospinal fluid (CSF) rhinorrhea have not been described. METHODS: A decision-tree analysis of imaging modalities used to localize CSF rhinorrhea was performed to compare associated direct costs. The primary outcome was cost, which was determined based on reimbursement data published by the Centers for Medicare and Medicaid Services in 2018. The model was parameterized after a literature review of published studies was performed from 1990 to 2018 to estimate the sensitivity CSF rhinorrhea localization of the following radiographic modalities: high-resolution computed tomography (HRCT), magnetic resonance cisternography (MRC), and CT cisternography (CTC). In addition to base case analysis, 1-way sensitivity analyses were also performed to evaluate the robustness of results to changes in model parameters. RESULTS: Among patients with a high suspicion for CSF rhinorrhea, use of HRCT followed by exploration in the operating room if preliminary HRCT was negative was found to be the optimal localization modality from a cost perspective ($172.25). The next least costly algorithm was HRCT followed by MRC ($294.10). Imaging algorithms beginning with CTC were the next least costly modality ($727.37). Sensitivity analyses generally supported HRCT to be the optimal initial radiographic strategy over a wide range of parameter values. CONCLUSION: This work advocates HRCT as first-line modality to localize CSF rhinorrhea from a cost perspective. Although algorithms beginning with MRC were on average $35 more expensive than those starting with CTC, associated risks of CTC were not modeled and may play a role in decision making.

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BACKGROUND: The objective of this work was to assess resident education regarding contemporary management of hereditary angioedema using a web-based survey. METHODS: An 11-item, multiple-choice, electronic questionnaire was sent to all 106 accredited otolaryngology training programs in November 2016. Questions focused on resident education, management principles, and formalized assessment. RESULTS: A total of 34 program directors responded, representing 32% of otolaryngology residences. Ninety-seven percent believed otolaryngology residents should be knowledgeable in the management of hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE). Specifically, 38% and 26% of program directors felt their residents were comfortable and very comfortable in C1-INH-HAE management, respectively. Of those surveyed, 18% have educational simulation activities and a protocol in place for C1-INH-HAE management. Forty-seven percent of respondents felt their training program provided adequate education and exposure to C1-INH-HAE. Over the last 5 years, 45% felt residents were exposed to 1 to 5 cases of C1-INH-HAE. Sixty-seven percent of residents were trained in the management of C1-INH-HAE through in-person lectures. Seventy-one percent of programs had no formal assessment of resident competency in C1-INH-HAE management. CONCLUSION: This study is the first to offer insight into C1-INH-HAE education and management principles in otolaryngology training programs. Surveyed program directors believe residents need a strong knowledge base in the management of C1-INH-HAE but less than half feel their trainees acquire the necessary exposure to this emergent disease process. Future research efforts in this area should aim to determine optimal educational activities as well as how to best incorporate this into otolaryngology residency curricula.

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