The PGIMER has successfully removed a large brain tumour through the nose of a 16-month-old girl, who is said to be the youngest patient in the world to have such an endoscopic surgery.

The girl from Uttarakhand was referred to the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, with complaints of loss of vision, according to a statement on 21 January. The child was normal and playful following visual stimuli a few months back. But later, the mother noticed that the girl was not following anything shown to her. An MRI scan revealed a calcified brain tumour at the base of the skull -- suggestive of craniopharyngioma of size 3 cm, large for a child of 1 year -- and close to critical neural structures like optic nerves and hypothalamus, the PGIMER said.

Doctors of the neurosurgery department -- Dr Dhandapani S S and Dr Sushant -- and Dr Rijuneeta of the ENT department operated upon the toddler. The large brain tumour was removed through the nose during the a six-hour-long surgery earlier this month, it said. The child was kept in the ICU and recovered very well. After 10 days of surgery, she is doing great with improved vision and no complications, with a CT scan showing almost complete removal, according to the PGIMER. It claimed that the youngest child reported till date having undergone endoscopic surgery through the nose for such tumours was two years old and operated in 2019 in Stanford, US. These tumours are usually operated on through open surgery and the remaining part is treated with radiation therapy.

Over the last few years, such tumours are being removed through the nose endoscopically by neurosurgeons by teaming with ENT surgeons for patients older than six years, the statement said. However, 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, it said.

"Despite the enormous challenge, Dr Dhandapani's team chose the endonasal corridor, as the skull opening and brain retraction are 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 laryngeal coblator were used during the initial steps. Reaching up to the tumour was difficult, as the bones and sinuses were immature. The typical air sinus, which usually gives a corridor to reach up to the tumour base, was absent in this child," the statement said, pointing out the challenges involved in the surgery. It said the nasal stage was performed by the ENT surgeon, while the skull base part was completed by the neurosurgeons.

Extensive drilling of the immature bones with a diamond drill was carried out using computer navigation to create a tumour removal corridor. It was dissected from critical structures using angled endoscopes and removed through the nose despite very little working space, the PGIMER said. As endonasal endoscopic surgery of brain tumour can cause brain fluid leakage through the nose. Therefore, the vascularised flap taken from inside the nose was used to seal the operative corridor along with fascia and glue, it added.