CHNDIGARH, 05.08.25-A girl child of 2 years from Amroha, Uttar Pradesh, was referred to PGIMER, Chandigarh, with complaints of worsening vision in both eyes over 4 months. The child was not able to see anything, and pituitary hormones were deficient at the time of admission. The child's MRI showed a giant calcified brain tumor (Craniopharyngioma) of size 4.5 cm under the central part of the brain, close to critical neural structures such as the optic nerves and hypothalamus. These tumors are usually operated on by opening the skull, and the remaining part is managed with radiation. Endoscopic removal through the nose is highly challenging in small children because of small nostrils, immature bones at the skull base, and proximity to crucial blood vessels. Dr. Dhandapani's team has previously published the first report in the world on endonasal surgery for craniopharyngioma of size 3.4 cm at 16 months of age. But tumors larger than 4 cm, called giant tumors, have never undergone surgery through the nose at 2 years of age, except once before at Stanford.

The team of Dr. Dhandapani SS, Dr. Rijuneeta, Dr. Shiv Soni, Dr. Sushant, Dr. Dhaval, and Dr Sanjog had operated on this giant brain tumor through the nose. Despite the enormous challenge, the endonasal corridor was chosen as the skull opening, and brain retraction is avoided if operated through the nose. The team studied the child elaborately using CT angiography navigation and planned for endoscopy. A thin high-definition endoscope, micro-instruments, and a laryngeal coblator were used during the initial steps. Reaching up to the tumor was difficult, as the bones and sinuses were immature. The typical air sinus, which usually gives a corridor to reach up to the tumor base, was absent in this child. The nasal stage was performed by ENT surgeon Dr. Rijuneeta, while the skull base part was completed by Dr. Dhandapani. Extensive drilling of the immature bones with a diamond drill was carried out using computer navigation to create a tumor removal corridor. The tumor was dissected from critical structures using angled endoscopes and removed through the nose despite very little working space.