Figure 1 - uploaded by Roy A. Holliday
Content may be subject to copyright.
Coronal temporal bone computed tomography image demonstrating indistinct tegmen tympani (arrow) with soft tissue density filling the middle ear. The contralateral tegmen appears intact (double arrows). 2
Source publication
Spontaneous temporal bone cerebrospinal fluid leak may be defined as a leak without an apparent precipitating cause. These transdural fistulas occur rarely, and diagnosis is predicated upon a high index of suspicion. Leaks have been reported through both middle and posterior fossa defects, although the vast majority involve the middle fossa plate....
Citations
... Most authors advocate a transmastoid (TM) repair for the treatment of small tegmental defects. The principal advantage of this option is the minimal invasiveness that allows to repair the dehiscence without manipulation and elevation of the dura of the middle cranial fossa (MCF) decreasing the risk of neurological complications [5][6][7]. Nevertheless, if a large temporal bone defect is observed in association with CSF leakage, more invasive surgical techniques are required. In this case a MCF approach allows a direct route and improves exposure of the entire tegmen and petrous apex. ...
... Yi et al. [31] Temporalis fascia + calvarian bone 11 0 0 36 Pappas et al. [7] Temporalis fascia + abdominal fat 12 0 n.a. n.a. ...
... Indeed observing the included studies in this review it appears that a combination of temporalis fascia with calvarian bone was the main used technique to repair the defect (Table 2). Although it is supposed that atrophy of the adipose tissue could lead to a recurrence of CSF leakage some authors [34,21,5,27,7] performed the repair using an abdominal fat graft. Interestingly two papers [8,26] described their outcomes in using hydroxyapatite cement to repair middle ear defect. ...
Objective:
Temporal bone CSF leak represents a rare condition that may be associated to some particular symptoms as hearing loss, otorrhea and tinnitus. In the opinion of many authors a surgical treatment is mandatory to avoid serious consequences as meningitis. Middle cranial fossa (MCF), transmastoid (TM) and combined approaches are all described to manage this condition. The objective of this paper was firstly to analyze the overall outcomes of this surgery. Our second aim was to make a comparison between different surgical modalities on the basis of their rate of success and complications.
Methods:
A search thorough Ovid MEDLINE was organized in January 2017 to enroll all eligible articles. A statistical analysis of the obtained data was performed.
Results:
Thirtythree studies comprising a total of 873 procedures were included. The overall rate of success resulted 95.6% (94.1–96.8). The rate of major complications analyzed for 818 procedures was 3.4% (2.3–4.8). Subgroups analysis showed a success rate of 97.1% (90.7–99.5) for TM approach. A success rate of 94.1% (89.1–97.3) was calculated for MCF approach. Combined procedure (TM + MCF) showed a success rate of 97.9% (92.9–99.7).
Conclusion:
The results of our review showed as the surgical treatment for CSF leak of temporal bone origin represents a safe option with high rate of success. Moreover our statistical data suggested that no significant differences are present in terms of outcomes between the analyzed surgical approaches.
... A bony tegmen tympani defect that associates with an epitympanic soft tissue density and a normal tympanic membrane and ossicular chain suggests herniated intracranial tissue. The surgical management of the temporal bone CSF is based upon defect location and patients the residual hearing ability of the patients [4]. In our case, patient was transferred to neurosurgery unit where he had a middle fossa approach to manage his CSF leak. ...
... In fact, this minimally invasive surgical approach allows repair of the dehiscence without manipulation and elevation of the dura of the middle cranial fossa (MCF). [11][12][13][14][15][16] However, when a large tegmen defect is found in association with CSF leakage, more invasive surgical techniques may be required. In this case, many authors adopt an MCF approach. ...
... Several approaches for tegmen repair have been proposed by different authors. 6,9,[11][12][13][14][15][16][17][18][19][25][26][27][28] The TM approach, the MCF approach, the combined approach, and the middle ear obliteration approach are the main ones described. ...
Objectives To describe our departmental experience in the surgical repair of tegmen tympani defects using a combined transmastoid/minicraniotomic approach.
Design Retrospective review of videos from surgery and patients' charts.
Setting Tertiary university referral center.
Participants Twenty-two patients who underwent surgical repair of tegmen defects associated with cerebrospinal fluid (CSF) leakage and/or meningocele/meningoencephalocele by a combined transmastoid/minicraniotomic approach.
Main Outcome Measures A retrospective review of videos of surgery and charts of patients with tegmen tympani or tegmen antri defects and CSF leakage, temporal lobe encephalocele, and/or meningoencephalocele.
Results All patients underwent the combined approach and had their defects closed, without significant intraoperative or postoperative complications.
Conclusions Mastoidectomy with temporal minicraniotomy represents an effective approach in patients with tegmen tympani dehiscence; the advantages of this technique are the control of the floor of the middle cranial fossa and the possibility to reach bony defects located anteriorly without manipulation of the ossicular chain and temporal lobe.
... In fact, this minimally invasive surgical approach allows repair of the dehiscence without manipulation and elevation of the dura of the middle cranial fossa (MCF). [11][12][13][14][15][16] However, when a large tegmen defect is found in association with CSF leakage, more invasive surgical techniques may be required. In this case, many authors adopt an MCF approach. ...
... Several approaches for tegmen repair have been proposed by different authors. 6,9,[11][12][13][14][15][16][17][18][19][25][26][27][28] The TM approach, the MCF approach, the combined approach, and the middle ear obliteration approach are the main ones described. ...
... Acquired MFCSF leaks most commonly result from destructive pathology such as tumors, infection, trauma, and surgical procedures, the latter two being the most common. 31 Congenital lesions such as patent Hyrtl fissure, Mondini dysplasia, and petromastoid canal fistulas occur much less frequently and typically occur in younger patients. 3,18,31,37 At older ages (usually > 50 years) chronically enlarged arachnoid villi can cause pulsatile erosion of pneumatized segments of the temporal bone, leading to transmission of CSF through the defect. ...
... 31 Congenital lesions such as patent Hyrtl fissure, Mondini dysplasia, and petromastoid canal fistulas occur much less frequently and typically occur in younger patients. 3,18,31,37 At older ages (usually > 50 years) chronically enlarged arachnoid villi can cause pulsatile erosion of pneumatized segments of the temporal bone, leading to transmission of CSF through the defect. 17 If there is no associated cause of a CSF leak, it is classified as spontaneous. ...
... 27,32 Persistent middle ear fullness, with or without sensorineural, conductive, or mixed hearing loss; progressive drainage of clear fluid after myringotomy; and recurrent meningitis can all be signs of an MFCSF leak. 3,10,26,27,31,32 Also, fluid in the mastoid air cells can be indicative of an MFCSF leak resulting from a tegmen mastoideum defect. 34 Persistent drainage of fluid following myringotomy can be confused with postprocedural infection. ...
Methods for repairing middle fossa CSF (MFCSF) leaks have varied and yielded mixed results. The objective of this study was to evaluate the safety and durability of the authors' repair technique using a novel combination of 3 synthetic materials.
The authors performed a retrospective case review of patients treated for CSF leaks between January 2009 and September 2011. Eight patients were found to have undergone middle fossa craniotomies for CSF leaks. Inclusion criteria for the study included age greater than 18 years, neuroimaging-documented temporal bone defect, and symptoms consistent with CSF leaks or gross CSF otorrhea. Seven patients, 3 men and 4 women, met the inclusion criteria, and their charts were reviewed. Hydroxyapatite cement, collagen-based dural substitute matrix, and polyethylene glycol hydrogel sealant were used in all patients for the repair.
In all patients the MFCSF leaks were successfully repaired. Initial presenting symptoms included CSF otorrhea in 4 patients (57.1%), hearing loss in 3 (42.9%), and CSF rhinorrhea in 1 (14.3%). The mean follow-up duration was 12 months (range 5-33 months). In 1 patient an epidural hematoma developed at the operative site on postoperative Day 2, and in another patient a superficial wound dehiscence occurred on postoperative Day 48. During the follow-up period, the authors found no evidence of wound infections, neurovascular damage, or CSF leakage requiring reoperation.
The middle fossa approach involving a combination of hydroxyapatite cement, collagen-based dural substitute matrix, and polyethylene glycol hydrogel sealant is a safe, effective method for repairing MFCSF leaks. The combination of synthetic materials provides an alternative to existing materials for skull base surgeons.
Objectives:
To evaluate clinical characteristics and outcomes of patients diagnosed with anterior (ASB) or lateral skull base (LSB) spontaneous cerebrospinal fluid (sCSF) leak.
Methods:
Single center retrospective review of patients diagnosed with sCSF leaks of ASB or LSB between 1/1/2009 and 11/1/2019 (n = 69). Body mass index (BMI), gender, age at diagnosis, origin of CSF leak (ASB vs LSB), surgical approach, lumbar drain use, recurrence, pre-operative diagnosis of diabetes mellitus (DM), and obstructive sleep apnea (OSA) were collected.
Results:
69 patients included in this study met criteria for sCSF leak without a traumatic or iatrogenic cause (Female: 51 (74%); average BMI: 37.0 ± 7.9). Forty-eight (70.0%) presented with sCSF leaks of the lateral skull base. All ASB leaks were treated with an endoscopic transnasal approach. Eleven (22.9%) LSB leak patients were treated using transmastoid approaches and 35 (72.9%) patients with a middle cranial fossa approach. Eleven patients (15.9%) reported sCSF leak recurrence. Two patients (9.5%) with anterior skull base and 9 patients (18.8%) with lateral skull base leaks had recurrence. LSB sCSF leaks had a relative risk of 2.192 of recurrence compared to ASB leaks (95% CI: 0.431-11.157, P = .483). A 5.017 times increased risk (95% CI: 1.285-19.583, P = .020) was reported for patients with OSA, while the risks for DM and BMI were 1.351 (95% CI: 0.67-9.105, P = .177) and 1.026 (95% CI: 0.963-1.094, P = .426) respectively. Patients with sCSF leak recurrence had significantly lower lumbar drain use (33.3%) than those without recurrence (72.7%) (P = .049).
Conclusion:
Spontaneous CSF leak recurrence is complex and multifactorial, and while patients with both DM and OSA had the higher risk of recurrence, OSA is likely an independent clinical risk factor for sCSF leak recurrence in this patient population.
A 19-year-old man with a history of Chiari type I malformation was admitted to our hospital two times within a 2-month period because of bacterial meningitis. Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis and hypoglycorrhachia. During the second admission, we became aware of hearing loss on the right since age 15 years. High-resolution temporal bone CT showed soft tissue opacification of the right epitympanum and external auditory canal. Tissue biopsy resulted in CSF otorrhea and pneumocephalus. CT cisternography revealed a temporal bone CSF leak. Brain MRI showed a dural defect localized to the anterior petrous apex. Using a combined middle cranial fossa-transmastoid approach, the dural defect and associated arachnoid granulations were located along the superior side of the greater petrosal nerve and repaired. A CSF leak without underlying pathology, such as trauma, surgery, or congenital abnormality, is defined as spontaneous. Spontaneous CSF leak should be considered as a cause of recurrent bacterial meningitis even when CSF otorrhea and fluid behind the tympanic membrane are clinically absent.
Objective
To determine whether the transmastoid approach to repair of spontaneous temporal bone cerebrospinal fluid (CSF) leak is safe and effective and if improvement in conductive hearing loss is an achievable goal with this approach.Study DesignCase series with chart review.SettingTertiary academic medical center.Subjects and Methods
Fifteen consecutive patients (16 ears) presented with spontaneous temporal bone CSF leaks over a 6-year period. Clinical data, imaging, audiometry, operative reports, and postoperative course were reviewed.ResultsMedian age was 59.5 years. Mean body mass index was 40.7 kg/m(2). All presented with chronic otorrhea after tympanostomy tube placement and conductive/mixed hearing loss. The mean preoperative air-bone gap was 19 dB. A transmastoid approach alone was used in 15 cases; 1 underwent middle fossa craniotomy. Most defects were located in the tegmen mastoideum and tympani. All repairs were multilayered, typically using autologous mastoid bone, temporalis fascia, and tissue sealant. Primary repair was successful in 15 cases; 1 patient with persistent postoperative otorrhea subsequently underwent middle fossa craniotomy, but no frank leakage was found. No serious complications were encountered. Following transmastoid repair, postoperative audiograms were available for 14 patients. The mean improvement in air-bone gap was 12 dB. Closure of the air-bone gap to ≤12 dB occurred in 100% of cases.Conclusion
The transmastoid approach to repair of spontaneous temporal bone CSF leak is highly successful. Furthermore, patients in this series had excellent hearing results with closure of their air-bone gap to ≤12 dB, which has not been previously described.
An abnormal communication between the subarachnoid spaces and the tympanic cavity and mastoid cells can determine a cerebrospinal fluid (CSF) leak in the air spaces of the temporal bone. The etiology of CFS leak in the temporal air cells includes acquired, congenital and spontaneous causes. Spontaneous CSF leak, defined as a leak without a manifest cause, is present in about 4% of cases and often occurs in the middle cranial fossa. We describe a case of spontaneous CSF leak in the right temporal air cells that mimicked a skull fracture in a subject with headache and apparent rhinorrhea after a head trauma. Both CT and MRI play a key role in the differential diagnosis between post-traumatic temporal CSF leak due to a fracture and spontaneous leak: traumatic CSF leak often does not require a surgical approach, whereas spontaneous CSF leak may need surgical treatment because of the risk of meningitis.
