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

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.

Introduction

A second-look endoscopic debridement is often performed in the first few weeks following endonasal skull base surgery (ESBS) to clear the sinonasal cavity and to assess the status of the surgical site. In the pediatric population, this may require returning to the operating room as younger patients are often unable to tolerate endonasal instrumentation unless under general anesthesia. There is currently no published evidence informing the utility of these second-look procedures for children under general anesthesia, which may impose additional risks and costs. In this study, we review the institutional experiences of two high-volume pediatric skull base surgery centers with these second-look procedures.

Methods

Patient Selection

This study protocol was approved by the Institutional Review Board at both institutions. We performed a retrospective analysis of pediatric patients (age <18 years) who underwent ESBS at two tertiary care pediatric academic hospitals between 2010 and 2021. At each institution, surgical case logs were reviewed to identify all patients undergoing pediatric ESBS cases. Patients were included if they underwent a planned second-look debridement under general anesthesia. If a patient underwent a second-look procedure prompted by a clinical concern (e.g., clinical suspicion of cerebrospinal fluid [CSF] leak, meningitis), they were excluded from this study.

It is the standard practice at both institutions to plan a second-look procedure under general anesthesia for all children younger than 12 years, given the general intolerance of nasal endoscopy in this age group. For pediatric patients between 13 and 18 years old, the need for a second-look procedure is determined based on extent of debridement anticipated, the patient's comfort with in-office endoscopy, and a discussion with the patient/family accounting for social and cultural factors.

Data Collection

Through a review of electronic medical records, demographics were recorded for each patient. For each index case, we recorded indication, primary versus revision surgery, and type of reconstruction. For the second-look procedure, operative reports were reviewed to capture intraoperative findings such as synechiae, infection, flap status, and CSF leak. Additionally, interventions performed such as lysis of adhesions, treatment of sinusitis, and revision of reconstruction were also recorded. Complications in the perioperative period of the second-look procedure were recorded. Finally, all subsequent clinic visits or hospitalizations were reviewed to capture any long-term sinonasal outcomes or complaints.

Statistical Analysis

For abnormal operative finding of flap complication, synechiae, and rhinosinusitis, a multivariate regression analysis was performed to identify any potential association with patient or clinical factors, including age, diagnosis, revision, presence of a flap, and time between index surgery and debridement.

Results

This study included 69 cases of second-look debridements, shown in Table 1 . The mean age of patients was 8.6 ± 4.2 years, range: 2 to 18 years. For the index surgery, the majority of cases (50/69, 72.5%) were performed for craniopharyngioma, 16/69 (23.2%) were revision cases, and 66/69 (95.7%) required a pedicled reconstruction to repair an intraoperative CSF leak. Second-look debridements occurred a mean of 18.3 ± 10.3 days following ESBS.

Table 1. Study population characteristics.

Age (y)	8.6 ± 4.2 (range: 2–18)
Sex
Male	47 (68.1%)
Female	22 (31.8%)
Race
White	39 (56.5%)
Black	7 (10.1%)
Asian or Pacific Islander	4 (5.8%)
Native American or Alaskan Native	1 (1.4%)
Other	18 (26.1%)
Ethnicity
Hispanic	9 (13.0%)
Non-Hispanic	60 (87.0%)
Pathology for index case
Craniopharygioma	50 (72.5%)
Germ cell tumor	3 (4.3%)
Optic glioma	3 (4.3%)
Rathke's cleft cyst	3 (4.3%)
Pituitary adenoma	2 (2.9%)
Cavernoma	1 (1.4%)
Chordoma	1 (1.4%)
Desmoid tumor	1 (1.4%)
Encephalocele	1 (1.4%)
Fibrous dysplasia	1 (1.4%)
Odontogenic keratocyst	1 (1.4%)
Pilocytic astrocytoma	1 (1.4%)
Teratoma	1 (1.4%)
Index case
Primary	53 (76.8%)
Revision	16 (23.2%)
Reconstruction of index case
None	3 (4.3%)
Nasoseptal flap	17 (24.6%)
Nasoseptal flap + fat	3 (4.3%)
Nasoseptal flap + fascia lata + fat	45 (65.2%)
Lateral nasal wall flap + fascia lata + fat	1 (1.4%)

Operative findings of the second-look procedure are shown in Fig. 1 . Abnormal findings were found in 11 of 69 (15.9%) cases, including nasal synechiae (8.7%), failed reconstruction with CSF leak (4.3%), and bacterial rhinosinusitis (2.9%). Of note, all cases of abnormal findings occurred in children ≤12 years of age.

Fig. 1.

Operative findings noted during second-look procedures, by patient age.

Synechiae occurred between the turbinates and the septum in four cases (example in Fig. 2A ) and within the olfactory cleft in two cases. In multivariate analysis, synechiae did not occur at a significantly higher rate in cases of younger patient age, sex, specific pathology, revision surgery, or cases with reconstructive flaps.

Fig. 2.

Second-look debridement following endonasal skull base surgery can enable ( A ) identification and lysis of intranasal synechiae and ( B ) detailed assessment of reconstructive flaps.

Of 66 cases where a reconstruction was performed, 63 (95.4%) flaps were noted to be viable and healing appropriately at the time of the second look (example in Fig. 2B ). There were three cases where a failed reconstruction was noted, all following expanded endonasal cases for craniopharyngioma. One nasoseptal flap was noted to be necrotic, prompting subsequent elevation of a new flap for reconstruction. Two nasoseptal flaps were found to be viable but with incomplete coverage of the defect allowing for persistent CSF leak—thus one reconstruction was augmented with a free mucosal graft, and another was augmented with an additional nasoseptal flap. On multivariate analysis, failed reconstruction was not significantly associated with age, sex, revision surgery, or time between index surgery and debridement.

There were two cases where acute bacterial rhinosinusitis was noted. In one case, purulence was identified emanating from the maxillary sinus, prompting treatment via a maxillary antrostomy. In one case, there was diffuse mucopurulence in both nasal cavities, prompting subsequent treatment with systemic antibiotics. Sinonasal infection was not significantly associated with patient age, diagnosis, revision, use of a flap, or time between index surgery and debridement.

There were no acute complications in the perioperative period. There was one instance of a patient who presented to the emergency department for an isolated fever of unclear etiology following second-look surgery, which did not result in any further intervention.

Long-term outcome data were not available for the majority of patients. This may be attributed to the two institutions serving as “destination” tertiary referral centers, with the long-term follow-up transitioned to practitioners in the patient's local setting following the acute postoperative period. Nonetheless, in cases where long-term data were available, two patients returned for an episode of acute bacterial rhinosinusitis, and four patients developed chronic rhinosinusitis. Incidence of sinusitis following second-look surgery was not significantly associated with patient age, diagnosis, revision, use of a flap, or time between index surgery and debridement.

Discussion

While second-look debridements are commonly performed following ESBS in children, this practice is primarily rooted in expert opinion ¹ rather than published evidence. A critical examination of this practice is warranted, as the literature surrounding endoscopic sinus surgery in children suggests limited to no benefit for second-look debridements, although this consists only of data regarding a subset of cystic fibrosis patients and data of limited quality from over two decades ago, and second-look debridements after sinus surgery are actually common practice at both tertiary care institutions in this study. ^{2 3 4} Of more consequence, any procedure under general anesthetic can impose an additional financial cost to the hospitalization, at an estimated average of $4,109 per case in these situations. ⁵ This is the first study assessing the utility of a planned second-look debridement for pediatric ESBS, providing preliminary data to support consideration of this practice.

In this series, the second-look debridement enabled identification and intervention for sinonasal pathology such as failed reconstruction, intranasal synechiae, and bacterial rhinosinusitis. In the pediatric population, which often may have difficulty articulating sinonasal symptoms and difficulty utilizing a sinus rinse which allows for appropriate healing in adult patients, second-look procedures under general anesthesia may provide a clinically meaningful benefit.

Nonviable reconstruction and CSF leak are particularly important to identify given the association with potentially significant complications such as meningitis and epidural empyema. ⁶ While the rate of identifying a failed reconstruction was relatively low in this cohort at 4.5%, the potentially grave consequences of missing this complication should be considered when deciding whether or not to perform a second-look procedure. Providing the opportunity to intervene before serious consequence ensues may save patients significant morbidity. Given this, second-look procedures may warrant particular consideration in children with pedicled reconstructions. Based on the Chabot et al's series, nasoseptal flap failure was more likely to occur in those who had undergone prior ESBS, so second-look procedures may prove especially useful in revision cases.

Regarding more minor abnormalities such as nasal synechiae or sinonasal purulence, the clinical significance of early intervention on these findings is currently unknown. Future controlled studies are certainly warranted to determine if early identification and intervention of these abnormalities have any impact on sinonasal quality of life. Nonetheless, in this series, all findings of synechiae and mucopurulence occurred in children ≤12 years, an age group that would generally have difficulty verbalizing symptomatology or tolerating in-office endoscopy. This suggests that children aged 12 years or younger may be the ones who have the most potential benefit to gain from a second-look procedure.

While there have not been studies on long-term sinonasal outcomes following pediatric ESBS, studies from adult cases cite the most frequently reported complaints of nasal crusting (50.8%), nasal discharge (40.4%), nasal obstruction (40.1%), and decreased sense of smell (26.7%). ⁷ Signs and symptoms of sinonasal morbidity typically last 1 to 4 months. ^{8 9 10} Interestingly, mucocele formation has been found to occur at a markedly higher rate in pediatric patients (25%) compared with adult patients (8%). ⁷ The effect of a debridement following ESBS on sinonasal outcomes has not been well studied for either the adult or pediatric population. When looking to the adult literature regarding debridement following endoscopic sinus surgery, the existing evidence is inconclusive. ¹¹ Two randomized controlled trials (RCTs) comparing debridement versus no debridement found no difference in patient-reported symptom scores or Lund–Kennedy endoscopy scores at 3 to 6 months. ^{12 13} By contrast, two RCTs demonstrated that debridement leads to quicker improvement in crusting and nasal congestion, and better long-term relief of nasal congestion. ^{14 15} A subsequent 2018 Cochrane review found low-quality evidence suggesting a decreased rate of adhesions at 3 months follow-up, though the clinical relevance of this finding is unknown. ¹⁶ Even among adults, the overall impact of in-office debridement following sinus surgery on long-term sinonasal quality of life is not well understood, despite this being a very common practice.

This study has several limitations. The retrospective nature limited the consistency of intraoperative data as it was susceptible to variable documentation and potential surgeon bias. Additionally, the institutions in this study often serve as “destination” tertiary care centers for pediatric ESBS, where care of patients is often transitioned to local institutions following the immediate postoperative period. This model may skew practice patterns toward performing a second-look surgery, which can provide a reassuring final check before the skull base surgery team loses accessibility to a patient. This model also limited the availability of long-term outcome data for many patients, hindering the ability to determine long-term clinical significance of the second-look procedure findings and interventions. Finally, the impact of second-look debridement on long-term outcomes is difficult to assess without a comparison group that did not undergo debridement, which was not available in this study due to the practice patterns of the institutions in this study. Nonetheless, our study provides preliminary data suggesting a beneficial utility of second-look debridement following ESBS, with minimal additional risk. Future prospective and controlled studies assessing long-term functional outcomes are warranted to examine the risks and benefits of second-look debridement in this patient population.

Conclusion

Following pediatric ESBS, second-look debridement procedures may allow for early identification and intervention for sinonasal pathology or nonviable reconstructions, and may have a particular benefit in children ≤12 years of age. The impact of second-look procedures on sinonasal outcomes in the pediatric population remains unknown. Larger, controlled studies are needed to assess the risk/benefit profile, refine indications, and inform optimal timing for these second-look procedures.