A 2-year-old child from Sonipat, Haryana, presented with worsening complaints of protrusion of the left eyeball, fixity of eye movements, snoring, a mass seen via the left nostril, and excessive watering of the eye. CT/MRI showed a 7 cm giant anterior skull base tumor involving the nose, sinuses, brain, and orbit. The biopsy turned out to be a meningioma. It is extremely rare in children, and the only other similar case reported previously in 2020 was in a 12-year-old girl from Spain who also needed open surgery.

Skull base meningiomas are some of the most challenging tumors to operate on, even in adults. At 2 years, it appeared to be a daunting task with a high risk to life due to hypothermia, blood loss, fluid disturbances, etc. Hence, a team was assembled to operate this child. Dr. Anurag, Dr. Rijuneeta, Dr. Kaushika from ENT, Dr. Dhandapani, Dr. Sushant, Dr. Bansil, Dr. Shilpi from Neurosurgery, Dr. Ankur, Dr. Poorna from Neuroanesthesiology, along with Mrs. Kanwaldeep, Mrs. Rajveer, Mrs. Jyoti, and Mr. Dhannaram from Nursing, managed the entire surgical procedure. The plan was to remove as much of the tumor as safely possible using an endoscope via the nose, and if needed, to go for open neurosurgery.

As the tumor was extending down through the nose and laterally involving the maxillary sinus and orbit, the child needed expanded endonasal endoscopy with the creation of additional space by nibbling the anterior cheekbone. Navigation, 45-degree angled endoscope, coblator, and long curved instruments were used innovatively to reach the upper part of the tumor adjacent to the brain. The tumor was very vascular, involving multiple bones and crevices. As the tumor was meticulously removed entirely with just endoscopy via the nose, the open neurosurgery was not required. The huge defect in the skull base created by the tumor was repaired in multiple layers. The preparation and procedure as a whole lasted 9 hours. The patient has improved after surgery. MRI has confirmed total excision.