The development of a pediatric skull base team: how, where and why?

Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6]. Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient. For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white. While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8]. While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices. Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches. While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered. The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies. Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6]. Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient. For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white. While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8]. While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices. Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches.While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.Purpose of reviewThe purpose of this review is to describe the development of pediatric skull base surgical techniques and illustrate the advantages of pediatric endonasal skull base surgery (ESBS) when applied in appropriate settings. Additionally, this manuscript endeavors to define the pediatric skull base team components, highlight circumstances amenable to the development of a pediatric skull base surgery team, and describe the relative advantages of independent pediatric teams versus incorporation with adult skull base practices.Multiple series published within the last decade have described the application of ESBS to the pediatric population, demonstrating adoption of these interventions in many academic centers. Most series include relatively small numbers of patients, highlighting the relative infrequency of anterior skull base pathology in the pediatric patient. Given the relatively low volume and high technical demands of this skillset, general guidelines for the timing, suggested training, and volume necessary to support a pediatric skull base team are offered.The interest in pediatric ESBS continues to expand though case volumes may limit maintenance of skills in lower volume centers. The development of a dedicated pediatric skull base team in areas where sufficient volume exists facilitates concentration of expertise and interdisciplinary relationships necessary to provide the highest level of care. Collaborating with adult skull base teams can enhance the pediatric team experience, increasing exposure to complex surgical planning and radiologic nuances. However, a pediatric-focused skull base team can tailor treatment to meet the specific psychosocial and developmental needs of children.Papers of particular interest, published within the annual period of review, have been highlighted as:The field of skull base surgery has made significant advancements in technology and surgical techniques, enabling the treatment of increasingly complex pathologies in a broadening patient population [1]. The anatomic complexities of the sinonasal cavity and skull base and its association to critical structures including the orbit, brain stem, and cranial nerves present a challenge for the surgical treatment of pathology in this region. Traditionally, open craniofacial approaches aimed at complete en-bloc resection were the standard of care, but there has been a shift towards endoscopic endonasal approaches when feasible as these approaches have demonstrated equivalent outcomes and potentially reduced morbidity due to decreased frontal lobe retraction [2,3]. no caption availableTreating anterior skull base lesions in the pediatric population poses specific challenges. Skull base tumors are rare in this population and can vary widely in pathology and origin [4]. Table 1 provides an overview of the pathologies and relative frequencies experienced in our pediatric skull base center. Pediatric skull base lesions are typically benign but may still cause significant morbidity due to mass effect on surrounding structures necessitating intervention. While traditional approaches such as anterior craniotomies, transfacial approaches, or combined craniofacial approaches were previously used, they carry additional risks in children, including damage to growth centers of the craniofacial skeleton and disruption of craniofacial sutures, which can affect long-term facial development [4,5]. These approaches may also require significant brain retraction and can result in undesirable cosmetic outcomes, such as disruption of tooth buds [6].Distribution of pediatric skull base pathology at pediatric skull base centerAn alternative approach, endonasal skull base surgery (ESBS), offers several advantages for pediatric skull base surgery. ESBS eliminates the need for significant brain retraction, and recent publications suggest that they do not impact craniofacial development in the pediatric population, despite impacting anterior skull base growth centers [5]. Of note, more recent data suggest that harvest of nasoseptal flaps or extended approaches can impact nasoseptal development [7]. Endoscopic approaches also provide improved visualization of the lesions through the intrinsic magnification of the lens and the ability to provide views beyond the direct line of sight using angled endoscopes. Additionally, specialized angled microinstruments facilitate manipulation and resection of lesions within these endonasal corridors. Endoscopic approaches may also provide better access to midline lesions, a factor especially relevant to many pediatric skull base pathologies. Limited studies also suggest that ESBS may lead to fewer complications, faster postoperative recovery, and reduced hospitalization costs compared to transcranial approaches [8].While ESBS has gained prominence in pediatric skull base surgery paralleling the adoption of these techniques in adults, unique challenges exist compared to adults. The inherently narrow space of the pediatric sinonasal cavity restricts visualization and light penetration. The endoscope and endoscopic instruments can limit each other's mobility, necessitating skillful navigation and strategic placement of these tools. This is especially relevant when a two-surgeon, four-handed technique is required for resection with several instruments working simultaneously. Anatomic factors like the size of the piriform aperture, intercarotid distances, and extent of sphenoid sinus pneumatization can further restrict the endoscopic approach and are impacted by both age and sex [9,10]. The size and thickness of the cranial bones can also affect intraoperative positioning and the decision to place skull pins for operative stabilization [11]. Another consideration is the lower blood volume reserve in children, requiring preoperative discussions with the anesthesia team regarding anticipated blood loss and the availability of blood products.Given the complexities involved in treating skull base pathologies, particularly in the pediatric population, developing a pediatric skull base team comes with many distinct advantages. Each pathology requires a tailored approach for resection and reconstruction, which requires the collaboration of various specialists. While the specific details of these approaches are beyond the scope of this manuscript, it is crucial to establish a core multidisciplinary team consisting of a neurosurgeon, otolaryngologist, and neuroradiologist when considering anterior and lateral skull base approaches. While the otolaryngologist's role is often thought to be the endoscopic approach, reconstruction, and visualization of the tumor, their responsibilities often blend with those of the neurosurgeon in a collaborative surgical environment during both the tumor dissection and reconstruction portions of the case. Other key members of the skull base team include endocrinologists, ophthalmologists, medical oncologists, radiation oncologists, and, in rare cases, microvascular free flap surgeons. The involvement of these subspecialties depends on the specific pathology and clinical presentation of the patient.For functional tumors, preoperative evaluation by the endocrinology team is necessary to manage perioperative and postoperative endocrine dysfunction related to the pathology and its treatment. If there are concerns about visual changes or optic nerve involvement, ophthalmologic assessments, including careful visual field evaluations, are required. In cases with difficult-to-access lesions, an oculoplastic surgeon with expertise in orbital approaches and reconstruction can enhance surgical access. The collaboration of medical oncology and radiation oncology teams is necessary when considering induction therapy or adjuvant therapy for pathologies like rhabdomyosarcomas or germinomas involving the skull base. Although utilized less frequently, a microvascular free flap surgeon may also be required for extended skull base repairs [12]. Additionally, experienced pediatric ancillary staff members, including those from the pediatric intensive care unit, child life specialists, and inpatient therapy options, play vital roles in the comprehensive treatment and care of pediatric patients.Developing a pediatric skull base team necessitates institutional resources and coordination among a multidisciplinary team. Therefore, It is important to first assess the feasibility and necessity of a pediatric skull base team based on the available resources and the overall volume of pediatric skull base cases. Despite the relative infrequency of individual pathologies, when addressing benign and malignant skull base tumors, congenital skull base pathologies and cranial base trauma, the volume of pediatric skull base cases in a tertiary or quaternary referral center can quickly rise to the level that warrants the development of an organized team.Determining the patient volume that justifies the establishment of a program can be challenging, balancing the need for expert care of patients and the infrequency of these pathologies. While there is no definitive threshold, the patient volume must be high enough for surgeons to maintain their skills and for centers to develop management protocols. The authors recommend consideration of a dedicated pediatric skull base team when a minimum of 12 cases are performed annually, which corresponds to an average of at least 1 case per month. This is, of course, a soft target and individual circumstances including level of training, proximity to other pediatric skull base centers, and patient mix all factor into the decision. The use of 3D-printed models in resident and fellow training, patient education, and preoperative surgical planning has been described and represents another potential avenue to help maintain skillsets in setting of lower clinical volume [13]. In the author's circumstance, a high level adult skull base practice at the adult affiliate institution provided guidance and surgical mentorship, facilitating a natural transition of care to the nascent pediatric skull base team. This growth and transition of pediatric skull base volume over time is represented in Fig. 1.Pediatric skull base program growth. Operative pediatric skull base (SB) volume is seen in black while all new pediatric skull base (SB) volume is seen in light gray. Transfers to the adult skull base team from the pediatric skull base team are seen in dark gray and overall pediatric skull base surgery at the adult hospital is seen in white.While there are no formal requirements for specific training in pediatric skull base care, team members should ideally have extensive experience in this area gained through clinical exposure and/or formal fellowships in pediatric subspecialties and/or skull base surgery. It is the authors' opinion that dual fellowships in pediatric otolaryngology and skull base surgery are not mandatory, but individuals without either fellowship training should have substantial clinical exposure to develop adequate skills.One of the key advantages of a pediatric skull base team is the collaborative and multidisciplinary approach to managing complex pathologies with low case volumes. Concentrating expertise and surgical skills can enhance understanding of these lesions, advance surgical techniques, and improve medical management. This is especially important since there is currently a paucity of evidence-based standards of care to dictate treatment in the pediatric population given the rarity of these pathologies.