Minimally Invasive Skull Base Surgery

Minimally invasive skull base surgery is an alternative approach to traditional open surgery. It involves removing tumors and treating other conditions through small incisions or natural openings, such as the nose.

Your child’s surgeon will use specialized surgical instruments, including a flexible tube with a light and a camera called an endoscope, to perform the procedure.

Sometimes called keyhole surgery, doctors use smaller incisions. This can mean:

• Less pain.
• Less scarring.
• Quicker healing.
• Shorter hospital stays.

Minimally invasive skull base surgery can treat a wide range of conditions, including:

• Acromegaly.
• Adenocarcinoma.
• Adenoid cystic carcinoma.
• Angiofibroma.
• Arachnoid cyst.
• Basilar invagination.
• Brain metastases.
• Cerebrospinal fluid (CSF) leak.
• Chiari malformation.
• Cholesterol granuloma.
• Chondroma.
• Chondrosarcoma.
• Chordoma.
• Craniofacial fracture.
• Craniofacial malformation.
• Craniopharyngioma.
• Cushing's disease.
• Dermoid and epidermoid tumors.
• Encephalocele.
• Esthesioneuroblastoma.
• Fibrous dysplasia.
• Glomus tumor.
• Hemangiopericytoma.
• Invasive fungal sinusitis.
• Inverted papilloma.
• Meningioma.
• Meningocele.
• Nasopharyngeal carcinoma.
• Neurofibroma.
• Odontoid pannus.
• Odontoid synovial cyst.
• Olfactory neuroblastoma.
• Optic nerve compression.
• Orbital inflammatory pseudotumor.
• Osteoma.
• Osteosarcoma.
• Paraganglioma.
• Pituitary adenoma (pituitary tumor).
• Pituitary apoplexy.
• Pseudotumor cerebri.
• Rathke cleft cyst.
• Rhabdomyosarcoma.
• Rheumatoid pannus.
• Sinus tumor.
• Squamous cell carcinoma.

Surgeons at UPMC have pioneered two minimally invasive skull base procedures: the endoscopic endonasal approach (EEA) and neuroendoscopic surgery.

Our pediatric neurosurgeons also have extensive expertise in minimally invasive endoscopic treatment for hydrocephalus. Hydrocephalus is a common pediatric condition that causes cerebrospinal fluid to build up in or around your child’s brain.

Your child’s care team will evaluate their condition and let you know if minimally invasive skull base surgery is an option. The process involves preoperative imaging, such as MRI and CT scans. Your child's care team may also order other tests, such as laboratory exams and vision testing.

Our multidisciplinary team approach will help determine the best course of action for your child. Their surgical team may include specialists such as:

• Pediatric neurosurgeons.
• Otolaryngologists (ear, nose, and throat specialists).
• Ophthalmic surgeons.
• Spine surgeons.

Your child's surgical team will let you know how early to arrive on the day of their surgery.

After your child has been registered, they will be taken to a "holding area." There, 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 your child the medications that will make them sleep during surgery. You will have the opportunity 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. At UPMC Children’s Hospital of Pittsburgh, these surgeries are performed in dedicated, state-of-the-art suites that incorporate sophisticated imaging technology.

When your child is asleep, the surgery will begin.

• Your child’s neurosurgeon will first load your child’s CT or MRI images into the image-guidance system. These images help your child’s doctor plan the procedure, create a precise surgical channel, insert the endoscope, and see the location of the surgical instruments in real time throughout the procedure.
• The surgeon will use an endoscope, an instrument that includes a light and a camera that transmits real-time video. This allows the surgeon to perform surgery while viewing the surgical area on the screen. Using image guidance, they can also see the location of the surgical instruments in relation to the surgical area and important structures in your child's skull.
• For the endoscopic endonasal approach, the surgeon will insert a specially designed endoscope through your child's nose and sinus cavities. For other minimally invasive procedures, they will make a small incision on the scalp or another area of the skull.
• The surgeon will make a small hole in the skull to access the tumor. They may also open the dura, the thick lining covering the brain.
• Using the endoscope and other specialized instruments, the surgeon will remove the tumor while sparing healthy tissue. For the endoscopic endonasal approach, the tumor is removed through the nose. For other procedures, the tumor is removed through the incision.
• The surgeon may take intraoperative imaging to verify that the tumor is removed.
• Once completed, the surgeon will remove the surgical instruments and repair the hole in the skull. For the endoscopic endonasal approach, they will put splints and packing in your child's nose. For other procedures, they will close the incision and place a bandage over the area.

Minimally invasive skull base procedures can take anywhere from two hours (for common EEA procedures) to several hours.

Some EEA 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.

Are there risks of minimally invasive skull base surgery?

All surgeries carry some risks. Risks of minimally invasive skull base procedures depend on the specific surgery, but they include:

• Bleeding in the brain.
• Cerebrospinal fluid leak.
• Increased pressure in the skull.
• Infection.
• Seizures.
• Stroke.

Complications are rarer with minimally invasive surgery than with open surgery. At UPMC Children's, we take every precaution to keep your child safe before, during, and after surgery.

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 for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• 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.

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 minimally invasive skull base surgery. After they are 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 of 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. 

Wound care

Before discharge, your child's care team will give you instructions on caring for your child's wound, including when to change bandages.

Nasal packing

If your child underwent the endoscopic endonasal approach, they will have compressible packing in their nasal passage after the procedure. This packing will remain in place for up to one week. They also will have plastic splints in the nasal passage, which will be surgically removed several weeks later.

Once 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 after surgery due to decreased air flow through the nose. This will often recover as healing occurs.

Bathing

• If your child has a skull incision, they should avoid getting their head wet or washing their hair for about a week after surgery. This gives their scalp and skull time to heal.

• Have your child take baths instead of showers to minimize the risk of water getting on their scalp.

Activity

After 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 sports.

To minimize the risk of a spinal fluid leak, your child will need to avoid activities that increase pressure of spinal fluid 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 after neuroendoscopy. Most children can resume their normal activities within six to eight weeks after the procedure.

Follow-up care

Your doctor will let you know when to schedule a follow-up appointment. If additional treatments are needed, your care team will assist you with scheduling appointments for your child.

Call the doctor right away if your child has:

• Bleeding or drainage from the surgical site.
• A fever higher than 101.4 F.
• Increased swelling or redness near the surgical site.
• Increased tenderness near the surgical site.
• Increased pain that is unexplained and/or does not respond to medication.
• Nausea, vomiting, diarrhea or constipation that is not improving.

If your child develops symptoms of confusion, weakness on one side of the body, drooping face, difficulty with movement or walking, or problems with vision or speech, dial 911. These could be a sign of a stroke or bleeding in your child’s brain.

If your child underwent the EEA, call their doctor right away if your child has drainage of clear fluid from their nose. This may be a sign of a cerebrospinal fluid leak.

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.