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Representative coronal CT image of preoperative tegmen dehiscence (arrow) and middle ear fluid signal. Postoperative coronal CT image of same patient after repair with Hydroset bone substitute (arrow). Not absence of middle ear fluid in postoperative image.
Source publication
Objective:
To determine the audiologic improvement after middle cranial fossa (MCF) approach to repair spontaneous cerebrospinal fluid (sCSF) leaks.
Study design:
Retrospective cohort study.
Setting:
Tertiary referral center.
Patients:
Twenty-four consecutive patients (27 ears) with temporal bone sCSF leak over a 4-year period. Patient age,...
Contexts in source publication
Context 1
... patients. The mean (SD) age of the 24 patients in the study was 60.8 [9.2] years with male patients constituting 25% (n ¼ 6) and female patients constituting 75% (n ¼ 18). The mean (SD) BMI of the study population was 37.8 [6.8] kg/m 2 . All patients underwent high resolution CT (HRCT) preoperatively and all patients had dehiscence of the tegmen (Fig. 1) otorrhea and documented complaints of hearing loss on the affected side simultaneously. All cases reported either clear otorrhea or hearing loss on the affected side (Table 1). Physical examination revealed 15 ears with intact tympanic membranes (TM), eight ears with pressure equalization tubes (PETs), and four ears with TM ...
Context 2
... of the patients with TM perforations or PETs received PET removals and/or tympanoplasty simultaneously during MCF approach or before the reported postoperative audiograms. Table 1 also provides an overview of the surgical findings from our cohort. All sCSF leaks were repaired using a multilayer reconstruction of the tegmen via the MCF approach (Fig. 1). In five ears (18.52%), the dehiscent area was purely over the tegmen tympani, while nine ears (33.33%) exhibited defects purely over the tegmen mastoideum. Concurrent defects of the tegmen tympani and tegmen mastoideum were noted in 13 ears (48.15%). Single dehiscent areas were seen in 12 ears (44.44%), while multiple areas of ...
Similar publications
Background:
Malformations of the temporal bone present different challenges to the implantation of a transcutaneous active bone conduction device, such as Bonebridge (Med-el, Innsbruck, Austria). This study aims to describe the benefits of high-resolution computed tomography (HRCT) in preoperative assessment and to analyze whether characteristics...
Citations
... A systematic review demonstrated a low rate of 6.6% of CSF leaks after MCF repair (2), which may be even lower with the use of bone cement for reconstruction (15). MCF repair with bone cement at our institution is safe and effective; hydroxyapatite appears as bone density on computed tomography (CT) imaging, allowing for the assessment of repair (16). ...
... The MCF approach has previously been described and is widely used for sCSF leak repair (4,16). Intraoperative mannitol at 0.5 g/kg was administered, and hyperventilation was performed to end-tidal CO 2 of less than 30. ...
Objective:
The timing for resuming continuous positive airway pressure (CPAP) postoperatively after skull base surgery remains controversial because of the risk of pneumocephalus. We determined the safety of immediate CPAP use after middle cranial fossa (MCF) spontaneous cerebrospinal fluid (sCSF) leak repair with bone cement.
Study design:
Prospective cohort study.
Setting:
Tertiary academic medical center.
Patients:
Thirteen consecutive patients with CPAP-treated obstructive sleep apnea and temporal bone sCSF leaks who underwent skull base repair with hydroxyapatite bone cement between July 2021 and October 2022.
Interventions:
CPAP use resumed on postoperative day 1 after the confirmation of skull base reconstruction with temporal bone computed tomography (CT).
Main outcome measures:
Postoperative skull base defects on CT, pneumocephalus, or intracranial complications.
Results:
The average age was 55.5 ± 8.8 years (±standard deviation), and 69.2% were female with a BMI of 45.39 ± 15.1 kg/m2. Multiple tegmen defects were identified intraoperatively in 53.9% of patients with an average of 1.85 ± 0.99 defects and an average defect size on preoperative imaging of 6.57 ± 3.45 mm. All patients had an encephalocele identified intraoperatively. No residual skull base defects were observed on CT imaging on postoperative day 1. No postoperative complications occurred. One patient developed a contralateral sCSF leak 2 months after repair. There were no recurrent sCSF leaks 1 month postoperatively.
Conclusion:
Immediate postoperative CPAP use is safe in patients undergoing MCF sCSF leak repair with bone cement because of the robust skull base repair.
... logic communication and preservation/repair of the ossicular chain. [15][16][17][18][19] The middle cranial fossa approach (MCFA), 2,5,6,[8][9][10]14,15 transmastoid (TMA), 5,8,13,14 and combined (MCFA + TMA) 1,5,8,10,12,14,18,19 approaches have been utilized. 16 The MCFA provides a panoramic exposure and facilitates direct dural suturing, but is associated with the morbidity of craniotomy. ...
... logic communication and preservation/repair of the ossicular chain. [15][16][17][18][19] The middle cranial fossa approach (MCFA), 2,5,6,[8][9][10]14,15 transmastoid (TMA), 5,8,13,14 and combined (MCFA + TMA) 1,5,8,10,12,14,18,19 approaches have been utilized. 16 The MCFA provides a panoramic exposure and facilitates direct dural suturing, but is associated with the morbidity of craniotomy. ...
... The MCFA is an extradural subtemporal approach performed through a temporal craniotomy that, when combined with anterior petrosectomy, addresses intradural lesions of the petrous apex, internal auditory canal, and posterior fossa. [10][11][12][13][14][15][16][17][18][19] When treating lateral pathology, such as MF encephaloceles, simple craniotomy and extradural elevation of the temporal lobe visualizes and facilitates primary suturing of dural defects. [1][2][3][4][5][6][7][8][9][10] Although the risk of craniotomy is low, drawbacks such as temporal lobe retraction, postoperative hematoma, 2,5,6,10 longer LOSx/LOS, 21,22 headaches, and wound breakdown 21-24 remain. ...
BACKGROUND
Middle fossa (MF) encephaloceles are rare lesions resulting from herniation through defects in the tegmen tympani or mastoideum. Underlying etiologies and clinical presentations are variable. Surgical goals include fistula obliteration, resection of nonfunctioning parenchyma, and dehiscence repair. The middle cranial fossa approach (MCFA), transmastoid approach (TMA), and combined (MCFA + TMA) approaches have been described. The minimally invasive TMA provides excellent exposure of the pathology and allows for ample working room to repair the defect.
OBJECTIVE
We present short-term follow-up results in patients treated via the TM repair at our institution.
METHODS
A retrospective review of patients with symptomatic encephaloceles treated via the TMA by our multidisciplinary team. Patient demographics, clinical presentations, intraoperative findings, repair technique, and outcomes were highlighted.
RESULTS
A total of 16 encephaloceles in 13 patients were treated. Defect etiologies included spontaneous (50.0%), secondary to chronic infection (25.0%), or cholesteatoma (18.8%). Defects were most often within the tegmen mastoideum (68.8%). Average length of surgery was 3.3 h (95% CI: 2.86-3.67) and length of stay 3.9 d (95% CI: 3.09-4.79). On short-term follow-up (average 11.5 mo), no patients experienced postoperative cerebrospinal fluid leak or recurrence. The majority of patients (83.3%) experienced confirmed improvement or stabilization of hearing.
CONCLUSION
MF encephaloceles present with various clinical manifestations and result from multiple underlying etiologies. The TMA is an alternative to craniotomy and our short-term results suggest that this approach may be utilized effectively in appropriately selected cases.
... They found that there was very minimal improvement in CHL in their own series (mean improvement in ABG of 2.6 dB only) following surgical repair of SME, though they did not analyze hearing outcomes according to surgical findings pertaining to the middle ear and ossicular chain. Alwani et al. (19) reported a persistent ABG of !15 dB postoperatively in 2 of 13 ears with both a tegmen tympani dehiscence and an encephalocele operated on via an MCF approach for spontaneous CSF leak. Several other articles report changes in CHL following tegmen repair (10,11,(19)(20)(21)(22)(23). ...
... Alwani et al. (19) reported a persistent ABG of !15 dB postoperatively in 2 of 13 ears with both a tegmen tympani dehiscence and an encephalocele operated on via an MCF approach for spontaneous CSF leak. Several other articles report changes in CHL following tegmen repair (10,11,(19)(20)(21)(22)(23). However, they include several different surgical approaches, including a transmastoid or combined approach with disarticulation of the ossicular chain in some cases. ...
Objective:
Conductive hearing loss (CHL) commonly arises in patients with spontaneous dehiscence of the tegmen of the temporal bone with meningoencephalocele (SME). The aim of this study was to further investigate 1) the potential mechanisms for CHL in this setting; 2) hearing outcomes following surgery to address SME, and 3) the possible causes of persistent CHL following surgery.
Study design:
Retrospective case review.
Setting:
Tertiary referral center.
Patients and intervention:
Seven patients (six female; nine ears) who underwent middle cranial fossa repair of SME and were found to have a tegmen tympani dehiscence from October 2010 to September 2014 were included in the study.
Main outcome measures:
Pre- and postoperative pure-tone audiometry.
Results:
Eight of nine ears (89%) had audiometric hearing loss at presentation. Seven ears (78%) had an air bone gap of ≥15 dB; all of these had an encephalocele traversing the tegmen tympani defect, four had a middle ear effusion, and three had a simultaneous superior semicircular canal dehiscence (SSCCD). The CHL resolved postoperatively in four of seven ears. Two of the three ears with persistent CHL had SSCCD. Attic ossicular fixation was identified in the other patient and the CHL resolved after ossiculoplasty.
Conclusions:
CHL associated with SME can be attributed preoperatively to ossicular chain fixation and synchronous SSCCD as well as the more commonly cited cerebrospinal fluid effusion and prolapse of meningoencephalocele onto the ossicular chain. Persistent postoperative CHL can also occur due to SSCCD and ossicular fixation by adhesions.
... [1][2][3][4]17,19 A recent data survey shows that the average age of patients diagnosed with spontaneous temporal CSF leaks is 56.9 years, ranging from 45.7 to 63 years. 3,6,[8][9][10]17,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] The patient's age in this report is, in a way, consistent with the hypothesis that spontaneous temporal CSF leak is associated with years of pulsation of intracranial content in regions of thin bones due to increased pneumatization, dehiscence or arachnoid granulations presence of the middle fossa floor. Regarding gender, most studies have noted a higher proportion of women to men in the development of spontaneous temporal CSF leaks, while others have not observed this trend. ...
... In patients with spontaneous temporal CSF leaks, approximately 13.1% will be associated to superior semicircular canal dehiscence. 10,17,24,27,28 The clinical presentation is usually insidious and nonspecific, which tends to delay the diagnosis. Usually the patient complains of aural fullness, dysacusis and tinnitus and presentes effusion in the middle ear on physical examination. ...
Spontaneous cerebrospinal fluid leaks of the temporal bone are uncommon conditions, but with increasing incidence in the last years. They represent the osteodural defect of the middle and posterior fossae floor with consequent communication between the subarachnoid space and the middle ear and mastoid cells, not associated with a history of trauma, chronic infections, tumors, surgery or irradiation. Physiopathogenesis is not well defined, being associated with the faulty development of the temporal bone and/or the presence of aberrant arachnoid granulations, in addition to being favored by idiopathic intracranial hypertension, obstructive sleep apnea and obesity. It has the potential for serious neurological complications, which is why surgical treatment is recommended. The main approaches involve transmastoid access and craniotomy access through the middle fossa, or a combination of both. This paper reports on a case attended at Grupo Santa Casa BH and performs a literature review and on aspects related to the clinical presentation and management of the condition.
... Surgical steps of the MCF approach have been previously well described. 15,16 We administer intraoperative mannitol (0.5 g/kg) and hyperventilate the patient to achieve an end-tidal CO 2 of <30 mmHg to facilitate temporal lobe relaxation. Lumbar drains (LD) are not used intraoperatively per findings of prior studies. ...
... Resolution of CHL with CSF leak repair has been described. 16 MCF repair of sCSF leaks demonstrates 96% of patients have closure of the air-bone gap postoperatively. 16 Combined MCF/TM approach also reported improved hearing outcomes on average, but not universally, 40 likely attributed to cases involving disarticulation of the incus-stapes joint for repair of tegmen tympani defects. ...
... 16 MCF repair of sCSF leaks demonstrates 96% of patients have closure of the air-bone gap postoperatively. 16 Combined MCF/TM approach also reported improved hearing outcomes on average, but not universally, 40 likely attributed to cases involving disarticulation of the incus-stapes joint for repair of tegmen tympani defects. ...
Objectives
To determine the safety and effectiveness of the middle cranial fossa (MCF) approach in repairing spontaneous cerebrospinal fluid (sCSF) leaks.
Study Design
Retrospective cohort study.
Methods
Patient with sCSF leaks repaired by MCF approach between January 1, 2014 and August 31, 2019 were included. Demographic information, clinical and surgical findings, and postoperative outcomes were recorded.
Results
The cohort (n = 45) included 24 tegmen repairs by multilayer reconstruction using hydroxyapatite cement and 21 cases of multilayer repair without hydroxyapatite cement. Ten MCF repairs were performed on patients ≥65 years old. Twenty (53%) ears had multiple tegmen defects (range, 1–9 tegmen defects) and 78% of patients had ≥1 encephaloceles. All sCSF leaks were resolved with one surgical intervention. There were no major intracranial complications. Transient expressive aphasia occurred in 2 patients. Medical complications occurred in four patients. There were no short‐term postoperative CSF leaks with bone cement reconstruction and two postoperative leaks without bone cement. One resolved with lumbar drain (LD) and the other resolved without treatment. The average (SD) length of stay (LOS) with bone cement was shorter than in patients without bone cement (2.54 [0.83] days vs. 3.52 [1.99] days, P < .05). There have been no long‐term CSF leak recurrences with an average (SD) follow‐up of 13.5 (12.9) months (range 0.25–46 months).
Conclusions
MCF approach for sCSF repairs demonstrate efficacious outcomes, particularly with tegmen reconstruction using hydroxyapatite cement. The approach exhibited no serious adverse events and few complications requiring intervention. Therefore, MCF is a safe and effective approach to resolve sCSF leaks.
Level of Evidence
3 Laryngoscope, 2020
Objective
We undertook a systematic review of the literature with meta‐analysis to identify the role of obesity (BMI ≥30) in the patient characteristics presenting with spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base and the outcomes of their repair.
Data Sources
A Systematic Review of English Articles using MEDLINE, EMBASE, and Cochrane Library.
Review Methods
The research algorithm included the following keywords: “spontaneous CSF leak,” “lateral skull base,” “temporal bone,” “meningocele,” “encephalocele,” and “otorrhea.” We also manually searched the references of included studies, to identify possible studies missed during our literature search.
Results
More than two‐thirds of the patients were female (69.2%) and often were obese (mean BMI 36.5 kg/m ² ) with a mean age of 57. Most common presenting symptoms were otorrhea and hearing loss. Most authors did not report a routine use of a post‐operative lumbar drain. Most patients had a single skull base defect and encephaloceles prolapsing through, across obese and non‐obese groups. Median length of stay in hospital was 3.2 days, and the majority of patients did not have any recurrence during their follow‐up (89.6%), which was not affected by obesity.
Conclusion
Obesity does not affect length of hospital stay or recurrence rate following surgical repair of lateral skull base sCSF leaks. Surgical repair is a safe and viable approach in the management of obese patients with sCSF leaks in the temporal bone.
Level of Evidence
N/A Laryngoscope , 2024
Objective:
To compare the presentation and outcomes of patients with and without obstructive eustachian tube dysfunction (oETD) undergoing repair of lateral skull base spontaneous cerebrospinal fluid (sCSF) leaks.
Study design:
Retrospective chart review.
Setting:
Tertiary referral center.
Patients:
Adults with lateral skull base sCSF leaks who underwent repairs from January 1, 2011, to December 31, 2020, were collected.
Main outcome measure:
Comparative statistics and effect sizes were used to compare clinical features, operative findings, and outcomes between groups.
Results:
Of 92 ears from 89 patients included, 51.1% (n = 47) had oETD. There were no differences in demographics between patients with and without oETD. Mean age was 60.7 ± 13.1 versus 58.5 ± 12.8 years (d = -0.17 [-0.58 to 0.24]), mean body mass index was 33.8 ± 8.5 versus 36.0 ± 8.0 kg/m2 (d = 0.27 [-0.14 to 0.68]), and female sex preponderance was 59.6% (n = 28) versus 68.8% (n = 31; Φ = -0.09), respectively. There were no differences in the radiologic number, size, and locations of defects. Patients with oETD had less pneumatized mastoids than those without oETD (p = 0.001; Φ = 0.43). Mean change from preoperative to postoperative air pure-tone average for those with and without oETD was -1.1 ± 12.6 versus 0.1 ± 17.2 dB (d = 0.09 [-0.04 to 0.58]), respectively. Six ears (6.5%; three with and three without oETD) underwent revisions for rhinorrhea/otorrhea between 5 and 28 months postoperatively, during which four leaks were found, the two patients without leaks had oETD.
Conclusions:
The presentation of sCSF leaks and outcomes of repairs in patients with oETD do not differ from those without oETD. Although postoperative otorrhea might represent an inflammatory or infectious process in patients with oETD, reexploration is warranted if patients do not improve with conservative treatment.
Objective:
To compare outcomes of surgical repair of temporal bone encephalocele and cerebrospinal fluid (CSF) leak using fibrin glue-coated collagen (FGCC) complex patch versus other materials for repair of dura.
Study design:
Retrospective chart review.
Setting:
Tertiary care hospital.
Patients:
Fifty-two adult patients undergoing transmastoid (TM), middle fossa (MF) or combined approach repair of spontaneous MF CSF leak between 2016 and 2020.
Interventions:
Exposure of bony defect via TM approach, MF craniotomy, or combined TM/MF, and repair of the associated dura defect with FGCC complex patch, or other materials (acellular collagen matrix, bovine collagen, autologous fascia, fibrin tissue sealant).
Main outcome measures:
Successful repair without recurrent CSF leak or encephalocele throughout follow-up. Cost of materials used in duraplasty.
Results:
Sixty-four percent of patients were female. Mean (standard deviation) age at repair was 61.4 (12.1) years. Mean (standard deviation) body mass index was 35.0 (8.3) kg/m2. Forty-nine (94%) patients had successful repair without known recurrence of CSF leak or encephalocele over a median follow-up interval of 11.7 months. Average duraplasty material cost was significantly lower with FGCC in comparison with other nonautologous materials (FGCC+: $1259.94, FGCC-: $1652.58; p = 0.004). No significant differences in recurrence risk (FGCC+: 6.9%, FGCC-: 6.9%; p > 0.999) or operative time (FGCC+: 153.7 min, FGCC-: 155.4 min; p = 0.88) were detected based on material used for duraplasty.
Conclusions:
All materials studied demonstrate effective and sustained means of repair for MF CSF leak and encephalocele, including in the presence of multiple defects. Use of FGCC for duraplasty produces noninferior surgical results to other nonautologous materials in repair of spontaneous CSF leaks of the temporal bone and may be more cost-effective.
