Endoscopic Endonasal Approach (EEA)

EEA is an innovative surgical technique used to remove skull base tumors and lesions — some as large as softballs — through your child’s nose, with no visible incisions required.

During the procedure, a pediatric neurosurgeon will use an endoscope — a tube with a light and a camera — and other specialized surgical instruments to remove your child’s tumor through their nose and sinuses.

Your child’s pediatric neurosurgeon will use stereotactic CT or MRI imaging guidance and intraoperative GPS technology to map the safest path to access the tumor. Imaging reduces the risk of damage to areas of the brain that control speech, movement, and other critical functions.

What is the skull base?

The skull base (or cranial base) is the part of the skull (cranium) that supports the brain and separates the brain from the rest of the head. Blood vessels to the brain and cranial nerves from the brain run through holes in the skull base. Below the skull base are the nasal passages, sinus cavities, facial bones, and muscles associated with chewing.

What are the benefits of EEA?

Benefits of EEA compared to traditional, open neurosurgery include:

• Faster recovery time — Recovery time after EEA surgery can be days rather than weeks or months. Your child may be able to leave the hospital within one to two days.
• Fewer side effects — With EEA, there are fewer — if any — lingering side effects when compared to traditional craniofacial surgery.
• No external incisions — EEA does not require incisions or disfigurement to your child’s skull or face. If your child has a cancerous tumor, they can start receiving chemotherapy or radiation treatment almost immediately, without needing to wait for incisions to heal. This gives these therapies the chance to start working sooner.
• Reduced risk of neurological damage — Your child’s brain does not have to be manipulated during EEA, reducing the likelihood of damage. Surgeons are better able to preserve important nerves that control vision and hearing.

After your child has been registered, he or she will be taken to a “holding area” where you will meet your child’s pediatric anesthesiologist and neurosurgeon. Your child’s pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will give the medications that will make your child sleep during the surgery. At this time, you will be able to ask any questions about the procedure. 

After your questions are answered and the operating room is prepared, your child will be taken into the operating room and given an anesthetic to make him or her go to sleep.

When your child is asleep, the surgery will begin. Your child’s neurosurgeon will:

• Load your child’s CT or MRI images into the image-guidance system. These images allow your child’s doctor to precisely plan and follow the safest path to the tumor, insert the endoscope, and see the location of the surgical instruments in real-time throughout the procedure.
• Insert a specially designed endoscope through your child’s nose and sinus cavities. The endoscope includes a light and a camera that transmits real-time video, allowing your surgeon to perform the procedure while viewing the surgical area on a screen. If your child’s doctor uses an image-guidance system, they will be able to see the location of the surgical instruments in relation to the surgical area and important structures in your child’s skull.
• Remove a small area at the base of your child’s skull to access the tumor.
• If necessary, open the dura — the thick lining covering your child’s brain.
• Insert instruments alongside the endoscope to remove the tumor through your child’s nose while sparing healthy surrounding tissue.
• Take intraoperative images, if needed, to verify that the tumor has been successfully removed.
• Repair your child’s skull base.
• Remove the endoscope.
• Insert plastic splints and packing inside your child’s nose.

Some surgeries are scheduled in two stages on separate days. The tumor is accessed in the first stage and then removed during the second stage several days later.

What are the risks of EEA?

Risks of EEA surgery depend on whether your child’s procedure requires your surgeon to open the lining of the brain called the dura.

If your child’s procedure does not require opening the lining of the brain, risks include:

• Bleeding
• Infection

If the lining of your child’s brain is opened, additional EEA risks include:

• Cerebrospinal fluid (CSF) leak.
• Meningitis.

What is the risk of a CSF leak after EEA?

If your child has a pituitary tumor or another tumor that can be removed without opening the dura, the lining of the brain, the chance of having a postoperative cerebrospinal fluid (CSF) leak and requiring follow-up surgery is very low — less than 2%.

If your child has a tumor that requires the surgeon to open the lining of their brain through their nose, such as to treat meningioma and craniopharyngioma, the risk of a CSF leak is slightly higher.

After EEA, our surgeons use a technique called the nasoseptal flap to repair the skull base. This technique involves taking tissue from the inside of your child’s nose and transplanting it into their skull base, lowering the chance of a spinal fluid leak after surgery to about 5.4%.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room to allow the anesthetic to wear off. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to their stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. This is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room.
• Once the anesthesiologist sees that your child is recovering and their pain is controlled, they will be moved to their hospital room. This usually takes about an hour, but every child is different, so times may vary.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is to stay calm yourself.

• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.
• During the surgery, at least one parent or guardian should remain in the surgical family waiting area at all times, in case the family needs to be reached.

Your child will be given pain medication after the surgery, which will help with discomfort when the anesthesia wears off. Your child’s doctor will give you instructions for how to administer pain medication at home after your child is discharged from the hospital.

Your child will need to spend at least one night in the hospital after neuroendoscopic surgery. After your child is transferred to a hospital room, they might still be groggy and should take it easy.

Diet

In the hospital, your child’s diet will be restricted to liquids, such as water, Gatorade®, Popsicles®, or Kool-aid® for a couple of hours to ensure their stomach is settled after the surgery. If your child does well with liquids after a couple hours, they may try a light diet and soft foods, such as applesauce, soup, toast, bananas, rice, or hot cereal. Your child may resume a normal diet the next day. 

Nasal packing

After your child’s surgery, their nasal passage will be filled with compressible packing that will remain in place for up to one week. Your child will also have plastic splints in their nasal passage, which are removed several weeks after surgery. After your child’s nasal packing is removed, you will need to spray their nasal cavity with saline (salt water) several times a day.

Your child may notice a decrease in smell and taste for several months following surgery due to decreased air flow through their nose. This will often recover as healing occurs.

Activity

Following the operation, activity needs to be somewhat restricted. Your surgeon will let you know when your child may resume normal activities, including returning to school and participating in gym or sports.

To minimize the risk of a CSF leak, your child will need to avoid activities that increase spinal fluid pressure inside their head, such as bending, lifting, straining, or nose-blowing, for a month after surgery.

Recovery time

Your doctor will let you know about your child’s expected recovery time. Most children can resume their normal activities within six to eight weeks after the procedure.

Follow-Up Care

You will need to schedule doctor’s appointments for your child every few weeks for several months after surgery. During your child’s follow-up appointments, your doctor will examine their nasal cavity and remove nasal crusts. By three to four months after surgery, healing is usually complete and crusting diminishes.

Additional follow-up depends on your child’s diagnosis, the need for additional treatment, and his or her symptoms.

You should call your doctor if your child has: 

• A fever of more than 100.0° F.
• Difficulty breathing.
• New or increasing shortness of breath.
• Pain, redness, bleeding, drainage, or increased swelling at the treatment site.
• Severe pain that does not respond to medication.

You should also call your doctor right away if your child has drainage of clear fluid from his or her nose. This may be a sign of a CSF fluid leak, which will need to be repaired using endoscopic surgical techniques.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. You may call the Pediatric Neurosurgery Division at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the presurgical examination on the day of the surgery. Call the division at 412-692-5090.

If your child has any special needs or health issues that the doctor should be aware of, please call the Pediatric Neurosurgery Division at UPMC Children’s before the surgery and ask to speak with a nurse. It’s important to notify us in advance about any special needs your child may have.