Spontaneous cerebrospinal fluid effusion of the temporal bone: repair, audiological outcomes, and obesity

Outcomes at 6 months after isolated or non-isolated surgery for temporal bone cerebrospinal fluid leak in adults: A STROBE analysis

AIM

The main aim of this study was to evaluate 6-month closure success in surgery for isolated or non-isolated temporal bone osteomeningeal breach (OMB). Secondary objectives were to analyze complications of closure and correlations between success and breach, treatment and patient data.

MATERIAL AND METHOD

This was a single-center retrospective observational study of patients who underwent surgery for temporal bone OMB via a middle cranial fossa or transmastoid approach in a French university teaching hospital between 2007 and 2022, with follow-up of at least 6months. Patients with superior semicircular canal dehiscence were excluded. Study data comprised gender, age, body mass index, OMB etiology, mode of discovery, audiometric and radiological data, surgical technique, length of hospital stay and postoperative complications. The primary endpoint was absence of a cerebrospinal fluid leak on MRI at 6months. Fisher's exact test or Chi2 test were used for qualitative data and Student t-test for quantitative data.

RESULTS

The closure success rate was 87%: 81% (3 recurrences) in the middle cranial fossa group of 16 patients and 93% in the transmastoid group of 14 patients. Postoperative audiometry showed significant improvement (P=0.0016) for air conduction in the middle cranial fossa group. Five patients (17%) operated on via the middle cranial fossa approach and 1 (7%) operated on via the transmastoid approach had postoperative complications. OMB was in the tegmen mastoideum in 8 patients (29%), tegmen tympani in 7 (25%), tegmen antri in 4 (14%), tegmina antri and tympani in 3 (11%), antri and mastoideum in 1 (8%) and in the whole tegmen in 5 (18%). Eleven OMBs were lateral to the superior semicircular canal, 13 medial and 4 on either side.

CONCLUSION

The transmastoid approach is indicated in case of associated middle-ear procedures, patients aged over 75years or OMB lateral to the superior semicircular canal. The middle cranial fossa approach is reserved for OMB located medial to the superior semicircular canal patients under 75years of age without associated ossicular procedures. For patients with OMB medial to the superior semicircular canal who require middle-ear surgery, a combined approach can be used.

Opioid Prescribing Patterns Following Lateral Skull Base Spontaneous Cerebrospinal Fluid Leak Repair

OBJECTIVE

To characterize the opioid prescribing patterns for and requirements of patients undergoing repair of spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adults with lateral skull base sCSF leaks who underwent repairs between September 1, 2014, and December 31, 2020.

MAIN OUTCOME MEASURE

Mean morphine milligram equivalents (MMEs) of opioids dispensed to inpatients and prescribed at discharge, additional pain control medications dispensed, and outpatient additional opioid requests were compared between groups.

RESULTS

Of 78 patients included, 46 (59%) underwent repair via a transmastoid (TM), 6 (7.7%) via a middle cranial fossa (MCF), and 26 (33.3%) via a combined TM-MCF approach. Inpatients received a mean of 21.3, 31.4, and 37.6 MMEs per day during admission for the TM, MCF, and combined TM-MCF approaches, respectively ( p = 0.019, ηp 2 = 0.101). Upon discharge, nearly all patients (n = 74, 94.9%) received opioids; 27.3, 32.5, and 37.6 MMEs per day were prescribed after the TM, MCF, and TM-MCF approaches, respectively ( p = 0.015, ηp 2 = 0.093). Five (6.4%) patients requested additional outpatient pain medication, after which three were prescribed 36.7 MMEs per day. Patients with idiopathic intracranial hypertension required significantly more inpatient MMEs than those without (41.5 versus 25.2, p = 0.02, d = 0.689), as did patients with a history of headaches (39.6 versus 23.6, p = 0.042, d = 0.684).

CONCLUSIONS

Patients undergoing sCSF leak repair via the MCF or TM-MCF approaches are prescribed more opioids postoperatively than patients undergoing the TM approach. Patients with a history of headaches or idiopathic intracranial hypertension might require more opioids postoperatively.

Fibrin Glue-Coated Collagen Complex Patch: A Novel Material for Surgical Repair of Spontaneous Temporal Bone Cerebrospinal Fluid Leak and Encephalocele

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.

Reliability of Home Sleep Apnea Testing for Diagnosing Obstructive Sleep Apnea in Patients With Spontaneous Cerebrospinal Fluid Leaks

STUDY OBJECTIVES

 To establish the prevalence of obstructive sleep apnea (OSA) in patients with spontaneous cerebrospinal fluid (sCSF) leaks and demonstrate the reliability of home sleep apnea testing (HSAT) to screen for OSA in this population.

METHODS

A literature review was performed to assess data on OSA prevalence in sCSF leaks. An institutional retrospective review was performed of 20 patients with sCSF leaks who met inclusion criteria. Patients without prior sleep studies were prospectively administered sleep studies, either HSAT or polysomnogram (PSG).

RESULTS

Twenty patients met the inclusion criteria. Two patients had prior sleep studies while 18 patients obtained prospective sleep studies following diagnosis and prior to management of sCSF leaks. Nineteen patients (95%) had evidence of mild or greater OSA.

CONCLUSIONS

 This study re-demonstrates the high prevalence of OSA in patients with sCSF leaks, consistent with current literature, and investigates the reliability of HSAT for diagnosis of OSA in this population.

Digital biosensor for human cerebrospinal fluid detection with single-use sensing strips

Leakage of human cerebrospinal fluid (CSF) caused by trauma or other reasons presents exceptional challenges in clinical analysis and can have severe medical repercussions. Conventional test methods, including enzyme-linked immunosorbent assay and immunofixation electrophoresis testing, typically are performed at a few clinical reference laboratories, which may potentially delay proper diagnosis and treatment. At the same time, medical imaging can serve as a secondary diagnosis tool. This work presented here reports the use of a point-of-care electrochemical sensor for detection of beta-2-transferrin (B2T), a unique isomer of transferrin that is present exclusively in human CSF but is absent in other bodily fluids. Limits of detection were examined via serial dilution of human samples with known B2T concentrations down to 7 × 10-12 g B2T/ml while maintaining excellent sensitivity. Nine human samples with varying levels of B2T were compared using up to 100 times dilution to confirm the validity of sensor output across different patient samples.

Recurrent spontaneous CSF rhinorrhea: combined endo-nasal endoscopic repair with lumbo-peritoneal shunt insertion

Background

Spontaneous cerebrospinal fluid (CSF) leaks are associated with high morbidity and recurrence rates. Most cases had increased intracranial pressure (ICP) on presentation. There is still controversy regarding the use of lumbo-peritoneal shunt to prevent its recurrence.

Aim

This study was conducted to evaluate the impact of lumbo-peritoneal CSF shunt following the initial as well as recurrent repair of spontaneous CSF leaks to avoid recurrence.

Methods

A retrospective cohort study reviewed patients with recurrent spontaneous CSF leaks over a 4-year period. All patients had increased ICP and were subjected to endoscopic repair and lumbo-peritoneal shunt procedure.

Results

Eighteen patients were included in this study. Most patients were obese (BMI = 33.6 ± 1.8 kg/m2) women (88.9%), with sleep apnea syndrome (77.8%). All patients presented with headache and visual complaints. Meningitis was recorded in two patients (11.1%). The most common sites of leakage were the cribriform (66.7%), followed by both cribriform and ethmoidal (16.7%), sphenoid (11.1%), and ethmoidal (5.6%) bones. The mean defect size was 5.1 ± 1.1 mm. About one third of cases had multiple defects. Encephalocele and meningocele were encountered in 61.1% and 66.7% of cases, respectively. The mean preoperative CSF pressure was 36.5 ± 1.7 mm H2O. Lumbo-peritoneal shunt was inserted for all our patients. The failure rate of repair was 11.1%.

Conclusion

Success rate is higher in patients with spontaneous CSF leaks and CSF hypertension treated by lumbo-peritoneal shunt. Future prospective studies with larger sample sizes should confirm the efficacy and safety of this management plan.

Management of patients with medically intractable epilepsy and anterior temporal lobe encephaloceles

OBJECTIVE

Temporal lobe encephaloceles (TLENs) are a significant cause of medically refractory epilepsy, but there is little consensus regarding their workup and treatment. This study characterizes these lesions and their role in seizures and aims to standardize preoperative evaluation and surgical management.

METHODS

Patients with TLEN who had undergone resective epilepsy surgery from December 2015 to August 2020 at a single institution were included in the study. Medical records were reviewed for each patient to collect relevant seizure workup information including demographics, radiological findings, surgical data, and neuropsychological evaluation.

RESULTS

For patients who presented to the authors' program with suspected medically intractable temporal lobe epilepsy (219 patients), TLEN was considered to be the epileptogenic focus in 5.5%. Ten patients with TLEN had undergone resection and were included in this study. Concordance between ictal scalp electroencephalography (EEG) lateralization and TLEN was found in 9/10 patients (90%), and 4/10 patients (40%) had signs suggestive of idiopathic intracranial hypertension (IIH). Surgical outcome was reported in patients with at least 12 months of follow-up (9/10). Patients with scalp EEG findings concordant with the TLEN side had a good outcome (Engel class I: 7 patients, class II: 1 patient). One patient with discordant EEG findings had a bad outcome (Engel class III). No significant neuropsychological deficits were observed after the surgery.

CONCLUSIONS

TLENs are epileptogenic lesions that should be screened for in patients with medically refractory epilepsy who have signs of IIH and no other lesions on MRI. Restricted resection is safe and effective in patients with scalp EEG findings concordant with TLEN.

Middle Fossa Encephaloceles Treated via the Transmastoid Approach: A Case Series and Review of the Literature

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.

Cerebrospinal Fluid Leaks From the Lateral Ventricle: A Case Series

OBJECTIVES

Describe the diagnosis and management of lateral skull base (LSB) cerebrospinal fluid (CSF) leaks originating from the lateral ventricle.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral academic center.

PATIENTS

Patients with CSF leaks with direct communication to the lateral ventricle on preoperative imaging.

INTERVENTION

Surgical repair via the middle cranial fossa (MCF) approach.

MAIN OUTCOME MEASURES

CSF leak patient characteristics (age, sex, body mass index [BMI]) and postoperative course (complications and CSF leak resolution) were collected.

RESULTS

Three patients had CSF leaks from the lateral ventricle and all patients demonstrated encephalomalacia of the temporal lobe on preoperative imaging. Encephalomalacia resulted from trauma in one case (age 5) and neurodegeneration in two cases (age 77 and 84). BMI ranged from 16.3 to 26.6 mg/kg2 and follow-up ranged from 4 to 21 months. Two patients presented with preoperative meningitis and all patients had resolution of CSF leaks after MCF repair. With the exception of the higher rate of meningitis, patient presentations did not differ from other spontaneous CSF leaks through middle fossa defects. There were no minor or major postoperative complications.

CONCLUSIONS

CSF leaks from the lateral ventricle represent a rare subset of LSB CSF leaks and can occur in non-obese patients secondary to temporal lobe encephalomalacia. The MCF approach allows for repair of the dura and skull base in this cohort of patients with high-flow CSF leaks and loss of brain parenchyma.

Spontaneous Tegmen Tympani Dehiscence: Causes and Treatment of Conductive Hearing Loss

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.

Anterior temporal encephaloceles: Elusive, important, and rewarding to treat

OBJECTIVE

To investigate the etiology and longitudinal clinical, neuropsychological, psychosocial, and surgical outcome profile of patients with medication refractory epilepsy and temporal encephaloceles with a view to highlight diagnostic clues and management strategies.

METHODS

The comprehensive epilepsy program databases at two surgical epilepsy centers from January 2000 to October 2018 were reviewed for this observational study, to identify patients with encephaloceles causing temporal lobe epilepsy (TLE) and treated with surgical resection. Their clinical, radiological, neuropsychological, psychiatric, and surgical data were obtained. Body mass index (BMI) data were also reviewed due to possible correlation between idiopathic intracranial hypertension and encephaloceles.

RESULTS

Thirteen patients (eight female) were identified; only three were recognized on initial magnetic resonance imaging (MRI) report. Temporal encephaloceles were identified on the left in eight patients, on the right in three patients, and bilaterally in two patients. One patient had a strong family history of encephaloceles. The median BMI for patients with seizure onset ≤20 years of age was 22.4, whereas for patients with onset >20 years median BMI was 32.6 (P = .06). Five patients underwent a focal lesionectomy, three patients had limited temporal lobectomy, and five patients had standard anterior temporal lobectomy. Median postoperative follow-up was 5.5 years. All but one patient were free of disabling seizures. Nine of ten neuropsychologically tested patients had no discernable cognitive decline postoperatively. Postoperative psychosocial adjustment features were present in four patients.

SIGNIFICANCE

Genetic factors and a possible association with idiopathic intracranial hypertension (given female predominance and elevated BMI) may contribute to the causation of temporal lobe encephaloceles. It is notable that a targeted surgical approach in the management of patients with TLE associated with encephaloceles has an excellent long-term clinical and neuropsychological outcome. Subtle encephaloceles should be actively searched for in patients with drug-resistant TLE because they significantly change surgical strategy and prognostication.

[Exudative otitis media as a manifestation of spontaneous otoliquorrhea]

Spontaneous otoliquorrhea (SOL) often mimics the picture of exudative otitis media (EOM), which leads to delayed diagnosis of the underlying disease.

PURPOSE OF STUDY

Is to evaluate causes, clinical features and diagnostic algorithm for patients with SOL.

PATIENTS AND RESEARCH METHODS

From 2007 to 2018, 33 patients with SOL underwent examination and treatment in the Department of Ear Microsurgery of the Institute. At the preoperative stage, all patients underwent a complete examination, including examination of ENT organs, anthropometric, biochemical, audiological, ultrasound and radiological tests, which made it possible to make the correct diagnosis.

RESULTS

SOL was more likely to occur in women over 50 who are obese (69.7%, stage II-III). The disease onset in 51.6% of patients was preceded by conditions accompanied by a short-term or prolonged increase in intracranial pressure. SOL was manifested by the clinical picture of EOM in 72.7% of cases, only in 45.5% of cases was accompanied by release from the ear and nose, was often intermittent and complicated by meningitis in 12.1% of patients. Difficulties in diagnosing the disease are caused by clinical manifestations of exudative or acute otitis media in the absence of a causative factor, which led to the verification of SOL from 1 to 4 years in 81.9% of patients who received long-term treatment for other ENT diseases.

CONCLUSION

The master factors in the diagnosis of SOL are otomicroscopy and endoscopy of the nasopharynx, Halo test and screening determination of glucose level in the obtained discharge, as well as high-resolution CT of the temporal bone, which allows to localize the cerebrospinal fluid fistula and to determine the size of the defect.

Severe Intracranial Hypotension After a Middle Fossa Approach for Spontaneous Otogenic Pneumocephalus

BACKGROUND

Spontaneous otogenic pneumocephalus is a rare condition caused by erosion of the tegmen tympani with subsequent entrance of air into the intracranial space. Its pathogenesis is thought to involve a previous state of intracranial hypotension, which pulls air into the intracranial cavity. The surgical management involves obliteration of the tegmen defect via a mastoidectomy or a middle fossa approach. Lumbar drainage has been used safely as an adjunct to middle fossa approaches so as to provide brain relaxation and decrease the incidence of postoperative cerebrospinal fluid leaks.

CASE DESCRIPTION

A 66-year-old male patient with otogenic pneumocephalus caused by nose blowing underwent repair of a tegmen tympani defect through a middle fossa approach, with the aid of intraoperative lumbar drainage. Progressive neurologic deterioration was seen postoperatively with obtundation and anisocoria. Computed tomography scans of the head demonstrated marked midline shift and transtentorial herniation. Recumbency and blood patch failed to improve the neurological condition. Intrathecal infusion of normal saline enabled clinical and radiological improvement.

CONCLUSIONS

Intraoperative lumbar drainage during a middle fossa approach for spontaneous otogenic pneumocephalus may dramatically aggravate a state of preexisting intracranial hypotension and lead to transtentorial herniation.

Middle Cranial Fossa Encephalocele and Cerebrospinal Fluid Leakage: Etiology, Approach, Outcomes

Objective  To compare outcome data for surgical approaches in the management of a middle cranial fossa encephalocele or cerebrospinal fluid (CSF) leak and, secondarily, to evaluate the role of obesity and the etiology of the defect. Design  Retrospective Setting  Quaternary referral center Participants  The study included 73 patients who underwent surgical repair of middle cranial fossa tegmen defects, two of which underwent bilateral repair. Outcome Measures  Demographic characteristics, clinical presentation, etiology, imaging, audiometry, surgical findings, method and material for repair, and postoperative course. Results  Fifty cases were spontaneous in origin, 2 were iatrogenic, and 23 were because of chronic otitis media. Of the 50, 18 underwent middle fossa craniotomy, 29 underwent a transmastoid approach, and 28 underwent a combined approach for repair. A postoperative CSF leak was seen in five patients: one who had undergone a transmastoid approach and four after a combined approach. There was no significant difference between the three approaches and risk of postoperative CSF fistulae. Two of the CSF fistulae resolved after a lumbar drain, and the remaining three patients required revision surgery. Conclusions  Middle cranial fossa tegmen defects are most commonly seen in obese females and are spontaneous in origin. The most common location was the tegmen mastoideum, and these defects were most commonly repaired through the transmastoid approach, with no greater risk of recurrence.

Management and Outcomes of Spontaneous Cerebrospinal Fluid Otorrhoea

Objective: A cohort of patients with spontaneous cerebrospinal fluid (sCSF) otorrhoea. To report surgical outcome and discuss a treatment protocol.

Materials and Methods: Between 2012 and 2018 all patients presenting with sCSF were collected and data assessment was performed including clinical symptoms (hearing loss, aural fullness, meningitis, recurrent otitis media), preoperative audiometry, CT and MRI scanning. According to the site and size of the dural defect, different surgical approaches were applied.

Results: A total of 12 patients (14 operations) were included. Four of these had a history of meningitis. All beta-trace protein testings were positive. These patients were treated with different surgical approaches: middle fossa approach (MCF, seven patients), transmastoid approach (TMA) with bony obliteration of the cavity (three patients), and four patients underwent a subtotal petrosectomy (STP) procedure. Three cases underwent revision surgery (MCF or STP) due to residual disease (CFS leakage). After follow up duration of 13 months (6.5 months SD), no recurrence was observed. No severe adverse events such as cerebrovascular injury, meningitis, wound infection, or headache was observed in the postoperative course.

Conclusion: Spontaneous aural cerebrospinal fluid leakage is a rare but manageable pathology with potential severe complications. Appropriate diagnosis, laboratory testing, and imaging is primordial to obtain optimal patient outcome.

Audiometric Outcomes and Middle Ear Disease following Cerebrospinal Fluid Leak Repair

OBJECTIVE

To investigate audiometric outcomes and incidence of chronic ear disease following lateral skull base repair (LSBR) of cerebrospinal fluid (CSF) leaks.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary skull base center.

SUBJECTS AND METHODS

Consecutive adults undergoing LSBR of CSF leaks between 2012 and 2018 were reviewed. Audiometric data included mean air conduction pure-tone average (PTA), air-bone gap (ABG), speech recognition threshold (SRT), and word recognition score (WRS). The incidence and management of the following were collected: effusion, retraction, otitis media and externa, perforation, and cholesteatoma.

RESULTS

Seventy-three patients underwent transmastoid (n = 5), middle cranial fossa (n = 2), or combined approach (n = 67) for repair of spontaneous leaks (sCSFLs, n = 41) and those occurring in the setting of chronic ear disease (ceCSFLs, n = 32). ABG decreased 7.23 dB (P = .01) in sCSFL patients. Perforations (P = .01) were more likely in ceCSFL. No sCSFL patient developed a cholesteatoma, perforation, or infection. Effusions (n = 7) were transient, and retractions (n = 2) were managed conservatively in the sCSFL cohort. Eight ceCSFL patients required tubes, 3 underwent tympanoplasties with (n = 2) and without (n = 1) ossicular chain reconstruction (OCR), and 1 had tympanomastoidectomy with OCR.

CONCLUSION

Lateral skull base repair of CSF leaks maintained or improved hearing. Patients with preexisting chronic ear disease were more likely to require additional intervention to sustain adequate middle ear aeration compared to the sCSFL cohort. LSBR of sCSFL does not appear to increase risk for developing chronic ear disease.

Is the Height of the Arcuate Eminence Related to Body Mass Index?

OBJECTIVES

To determine the relationship, if any, between body mass index (BMI) and attenuation of the arcuate eminence (AE).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary neurotologic referral center.

SUBJECTS AND METHODS

Submillimeter distances were recorded from high-resolution temporal bone computed tomography (CT) scans of 50 patients (100 sides). The AE (defined as the superiormost location of the petrous bone over the otic capsule), the bony apex of the superior semicircular canal (SSC), and the geniculate ganglion (GG) were identified and 3-dimensional distances measured. The height of the AE relative to the bony apex of the superior semicircular canal was determined using Euclidean geometry using the fixed anatomical landmark of the GG as the origin. Correlations between AE and BMI were calculated using Pearson's, linear mixed effects, and sensitivity analysis models.

RESULTS

The mean (SD) BMI was 30 (8.1) kg/m², with 16 (30%) patients falling in the underweight/normal category (BMI <25 kg/m²), 10 (20%) overweight patients (25 kg/m²≤ BMI ≤ 30 kg/m²), and 24 (48%) patients considered obese (BMI >30 kg/m²). The mean (SD) AE heights for the left and right ears were 2.5 (1.11) and 2.6 (1.09), respectively. The results of the linear mixed-effects models indicated little evidence that BMI is associated with AE height when including all patients (partial R² = 0.040) and when using BMI categories (partial R² = 0.025).

CONCLUSION

Contrary to other structures within the lateral skull base, the relative prominence of the arcuate eminence does not correlate with BMI or any other demographic variables.

Impact of Obesity and Obstructive Sleep Apnea in Lateral Skull Base Cerebrospinal Fluid Leak Repair

OBJECTIVE

To investigate the prevalence and impact of obstructive sleep apnea (OSA) and obesity in lateral skull base cerebrospinal fluid leak repair (LSBR) of various etiologies.

METHODS

Retrospective case review at a tertiary skull base center was conducted of consecutive adults undergoing LSBR via transmastoid, middle cranial fossa, or combined approach between 2013-2018. The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma or chronic ear disease were excluded.

RESULTS

Ninety-four patients (67.4% female, mean age 53.5 ± 12.9 years) underwent repair for spontaneous (sCSFL, 44%) and other etiology (nsCSFL) leaks. nsCSFL served as a comparison group consisting of leaks status-post lateral skull base surgery, temporal bone fractures, and chronic ear disease. Class III obesity (P = .02), OSA (P = .03), and imaging findings of empty sella (OR = 3.32, P = .02), and skull base thinning including contralateral tegmen thinning (31%, OR = 4.3, P = .02), arachnoid granulations (26%, OR = 4.35, P = .02), and superior canal dehiscence (15.8%, OR = 8.57, P = .04) were more common in sCSFL. Four patients (4.2%) required surgical revision for recurrence, and another four (4.2%) resolved with shunting. Evidence of elevated intracranial hypertension was present in nine patients with sCSF leaks and was predictive of need for revision or shunt procedures (P < .01).

CONCLUSION

Obesity, OSA, and imaging consistent with elevated intracranial pressures were more common among patients with sCSFL. Elevated intracranial pressure predicted outcomes following multilayer repair of spontaneous CSF leaks LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2234-2240, 2020.

Trans-mastoid approach for cerebrospinal fluid leak repair

PURPOSE OF REVIEW

To describe the technique and discuss the advantages and outcomes of the trans-mastoid approach (TMA) for temporal bone cerebrospinal fluid (CSF) leak.

RECENT FINDINGS

TMA for CSF leak repair is an alternative to middle cranial fossa approach (MCFA) with less morbidity and good outcomes.

SUMMARY

Persistent CSF leak in the temporal bone whether idiopathic, congenital or acquired, is an indication for surgery. TMA is a valid option for surgery, competing with MCFA in selected cases. Surgical technique consists of a standard mastoidectomy, exposure of the osteodural defect, and repairing it using multiple layers in an inlay and overlay fashion. Outcomes show low recurrence and complication rates with good hearing results. However, long-term follow-up should be made, as recurrences can be delayed.

Postoperative management of patients with spontaneous cerebrospinal fluid leak

PURPOSE OF REVIEW

To explore key management principles and outcomes following surgical intervention for spontaneous CSF leaks of the lateral skull base.

RECENT FINDINGS

Outcomes following surgery for spontaneous CSF leaks of the lateral skull base depend on the surgical approach utilized. The approach reported most frequently in the literature is currently the middle fossa approach. Mean leak recurrence rates, regardless of approach, were approximately 6%. The lowest leak recurrence rates were associated with the combined middle cranial fossa-transmastoid approach. A multilayer closure was employed in all of the reviewed investigations, but the choice of reconstructive material did not significantly affect outcomes. Direct surgical complications rates, overall, were low at less than 2%. Meningitis, intracranial hemorrhage, and perioperative seizure activity were only rarely encountered. A concomitant diagnosis of idiopathic intracranial hypertension was found to be associated with increased rates of leak recurrence and sequential leak development at other skull base sites.

SUMMARY

Postoperative management of patients with spontaneous CSF leaks of the lateral skull base has unique challenges. Observation of key treatment principles can lead to good outcomes and limit morbidity. A high index of suspicion should exist for concomitant idiopathic intracranial hypertension.

Utility of Magnetic Resonance Imaging in Differentiating Cerebrospinal Fluid Leak from Middle Ear Effusion

Objective

To demonstrate the clinical utility, sensitivity, and specificity of standard magnetic resonance imaging (MRI) sequences in differentiating temporal bone cerebrospinal fluid leaks from all other middle ear effusions.

Study Design

Retrospective imaging review.

Setting

Academic medical center.

Subjects

Patients with cerebrospinal fluid leaks or other middle ear effusions who also underwent MRI.

Methods

Patients were assigned to cerebrospinal fluid leak and other effusion cohorts based on clinical course, findings at surgery/myringotomy, and beta-2 transferrin fluid analysis. Reviewers blinded to the clinical outcome examined T1-weighted, T2-weighted, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR), and 3-dimensional (3D) acquired T2-weighted MRI sequences. For each sequence, fluid imaged in the temporal bone was graded as either similar or dissimilar in signal intensity to cerebrospinal fluid in the adjacent subarachnoid space. Signal similarity was interpreted as being diagnostic of a leak. Test characteristics in predicting the presence of a leak were calculated for each series.

Results

Eighty patients met criteria (41 leaks, 39 other effusions). The 3D T2 series was 76% sensitive and 100% specific in diagnosing a leak, and FLAIR was 44% sensitive and 100% specific. The T1-weighted (73% sensitive, 69% specific), T2-weighted (98% sensitive, 5.1% specific), and diffusion-weighted (63% sensitive, 66% specific) series were less useful.

Conclusions

MRI, with attention to 3D T2 and FLAIR series, is a noninvasive and highly specific test for diagnosing cerebrospinal fluid leak in the setting of an indeterminate middle ear effusion.

Management of spontaneous temporal bone cerebrospinal fluid leak: A 30-year experience

PURPOSE

The goal of this study was to describe the incidence of and our long-term results in the management of spontaneous temporal bone CSF leak and to determine if there is any association with an increase in body mass index (BMI).

METHODS

This was an Institutional Review Board (IRB) approved retrospective review of 58 patients who underwent repair of spontaneous temporal bone CSF leaks by a single surgeon at a tertiary care academic medical center between 1988 and 2017. Patients with CSF leaks due to trauma, iatrogenic injury, or chronic infection were excluded. Surgical approaches included middle cranial fossa, transmastoid, or a combination of both. Cases were divided into three decades. Patient demographics, clinical features, audiologic results, imaging studies, operative findings, complications, and long-term results were reviewed with a specific emphasis on the potential correlation with BMI.

RESULTS

The average BMI was 32. There was a statistically significant increase in BMI between the two most recent decades (p = 0.044). The middle cranial fossa was the most commonly utilized approach. Multiple tegmen defects were often noted on imaging and intraoperatively.

CONCLUSION

There is an increase in the incidence of spontaneous CSF leaks possibly associated with an increase in BMI in the United States over the last 30 years.

Cerebrospinal fluid rhinorrhea in a bilateral frontal decompressive craniectomy patient caused by strenuous activity: A case report

RATIONALE

Iatrogenic cerebrospinal fluid (CSF) rhinorrhea in a bilateral frontal decompressive craniectomy patient triggered by strenuous sport is rare. To the best of our knowledge, no similar case has yet been reported.

PATIENT CONCERNS

Herein, we report a case of CSF rhinorrhea in a 37-year-old man. He had previously suffered a traumatic brain injury in a traffic accident, and a subsequent bilateral frontal decompressive craniectomy operation was performed. Based on the frontal skull defect peculiarity, strenuous exercise may have caused drastic CSF pressure waves to tear the dura mater of the anterior skull base, resulting in CSF rhinorrhea.

DIAGNOSES

The thin-slice computerized tomography (CT) images revealed a frontal skull defect and the open frontal sinus. In addition, in the opened frontal sinus, low-density liquid-filled areas were visible.

INTERVENTIONS

During surgery, the torn dura was carefully repaired, and the frontal sinus was filled with temporal muscle, fascia, and fibrin glue. A simultaneous cranioplasty was performed.

OUTCOMES

The patient was followed-up postoperatively for 12 months to date without rhinorrhea recurrence. Recovery was uneventful.

LESSONS

Patients with skull defects should avoid strenuous sports, and cranioplasty should be performed as early as possible in order to decrease the likelihood of a dural tear and prevent the occurrence of CSF leakage. After cranioplasty, the skull should be restored to a closed state to reduce the damaging effects of CSF waves during movement. It is important to maintain normal intracranial pressure to reduce the recurrence rate of CSF rhinorrhea.

Surgical outcomes in the treatment of temporal bone cerebrospinal fluid leak: A systematic review

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.

Middle Cranial Fossa (MCF) Approach Without the Use of Lumbar Drain for the Management of Spontaneous Cerebral Spinal Fluid (CSF) Leaks

OBJECTIVE

To determine the efficacy and morbidity of repairing spontaneous cerebrospinal fluid (CSF) leaks with the middle cranial fossa (MCF) approach without the use of a lumbar drain (LD), as perioperative use of LD remains controversial.

STUDY DESIGN

Retrospective review from 2003 to 2015.

SETTING

University of Iowa Hospitals and Clinics and Indiana University Health Center.

PATIENTS

Those with a confirmed lateral skull base spontaneous CSF leaks and/or encephaloceles.

INTERVENTION

MCF approach for repair of spontaneous CSF leak and/or encephalocele without the use of lumbar drain. Assessment of patient age, sex, body mass index (BMI), and medical comorbidities.

MAIN OUTCOME MEASURE

Spontaneous CSF leak patient characteristics (age, sex, BMI, obstructive sleep apnea) were collected. Length of stay (LOS), hospital costs, postoperative complications, CSF leak rate, and need for LD were calculated.

RESULTS

Sixty-five operative MCF repairs were performed for spontaneous CSF leaks on 60 patients (five had bilateral CSF leaks). CSF diversion with LD was used in 15 of 60 patients, mostly before 2010. After 2010, only three of 44 patients (6.7%) had postoperative otorrhea requiring LD. The use of LD resulted in significantly longer LOS (3.6 ± 1.6 versus 8.7 ± 2.9 d) and hospital costs ($29,621). There were no postoperative complications in 77% (50 of 65) of cases. Three cases required return to the operating room for complications including frontal subdural hematoma (1), subdural CSF collection (1), and tension pneumocephalus (1). No patients experienced long-term neurologic sequelae or long-term CSF leak recurrence with an average length of follow-up of 19.5 months (range 3-137 mo). The average patient BMI was 37.5 ± 8.6 kg/m. The average age was 57.5 ± 11.4 years and 68% were female. Obstructive sleep apnea was present in 43.3% (26 of 60) of patients.

CONCLUSION

The morbidity of the MCF craniotomy for repair of spontaneous CSF leaks is low and the long-term efficacy of repair is high. Universal use of perioperative lumbar drain is not indicated and significantly increases length of stay and hospital costs. Obesity and obstructive sleep apnea are highly associated with spontaneous CSF leaks.

Posterior Fossa Spontaneous Cerebrospinal Fluid Leaks

OBJECTIVE

Describe the diagnosis and management of spontaneous lateral skull base cerebrospinal fluid (CSF) leaks that originate from the posterior fossa.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary university hospital.

PATIENTS

Adult patients from 2005 to 2015 who underwent surgical repair of a spontaneous lateral skull base CSF leak with intraoperative confirmation of a posterior fossa leak source.

INTERVENTION

Surgical repair.

MAIN OUTCOME MEASURES

CSF leak resolution.

RESULTS

Five patients had CSF leaks from the posterior fossa. The mean age at presentation was 54 years old (range, 19-79), the mean body mass index (BMI) was 32.6 (standard deviation [SD], 8.4), and the mean follow-up length was 34.6 months (SD, 19.4). Presentations did not differ from CSF leaks through middle fossa defects, including three patients with a history of meningitis and all patients with clear otorrhea following tympanostomy tube placement. All patients had resolution of the leak after surgical repair, but two patients required revision surgery for persistent leaks and one patient had a postoperative infection. Surgical approaches included one middle fossa, two transmastoid, one combined middle fossa/transmastoid, and one transcanal. Radiographic studies suggested a posterior fossa source in all cases but findings were often subtle.

CONCLUSION

Posterior fossa CSF leaks represent a rare subset of spontaneous lateral skull base leaks. Diligent radiographic review and intraoperative assessment of the posterior fossa plate are crucial. The size and location of the defect dictates the optimal surgical approach. Surgeons should consider a posterior fossa source in failed repairs or when the initial surgery did not fully evaluate the posterior fossa plate.

Spontaneous Cerebrospinal Fluid Rhinorrhea: Association with Body Weight and Imaging Data

Objective  Spontaneous cerebrospinal fluid rhinorrhea (SCSFR) might be the only clinical manifestation of idiopathic intracranial hypertension (IIH), which has been historically related to overweight. Our goal was to search for an association between SCSFR and increased body weight on the one hand and SCSFR and imaging findings suggestive of IIH on the other hand. Materials and Methods  We retrospectively collected clinical and radiological data of patients operated on endoscopically for SCSFR in our institution from 1993 to 2013. Analyzed factors were body mass index (BMI), extended sphenoid sinus pneumatization on computed tomography, and empty sella and distention of the optic nerve sheath on magnetic resonance imaging. Results  There were 15 patients: 8 females/7 males; mean age 50 years. Primary surgical success rate was 86.7%. Regarding body weight, 80% were overweight (BMI ≥ 25) versus 32% in the French general population ( p  < 0.001). Among patients with SCSFR, 20% were obese (BMI ≥ 30) versus 15% in French individuals without SCSFR ( p  = 0.483). Increased pneumatization of sphenoid sinuses was observed in 92.9 versus 27.5% in the general population ( p  < 0.0001). Empty sella was found in 46.2 versus 3% in the general population ( p  < 0.00001). Dilation of the optic nerve sheath was observed in 46.2 versus 15% in the general population ( p  < 0.01). Conclusion  We found statistically significant associations between SCSFR and overweight, increased pneumatization of sphenoid sinuses, empty sella, and dilation of optic nerve sheath, but not with obesity, which did not have any additional impact of CSF leak than did overweight.

Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review

Objectives

To review the safety and efficacy of surgical management for spontaneous cerebrospinal fluid (CSF) leaks of the anterior and lateral skull base.

Data Sources

A systematic review of English articles using MEDLINE.

Review Methods

Search terms included spontaneous, CSF, cerebrospinal fluid, endoscopic, middle fossa, transmastoid, leak, rhinorrhea. Independent extraction of articles by 3 authors.

Results

Patients with spontaneous CSF leaks are often obese (average BMI of 38 kg/m²) and female (72%). Many patients also have obstructive sleep apnea (∼45%) and many have elevated intracranial pressure when measured by lumbar puncture. In addition to thinning of the skull base, radiographic studies also demonstrate cortical bone thinning. Endoscopic surgical repair of anterior skull base leaks and middle cranial fossa (MCF) approach for repair of lateral skull base leaks are safe and effective with an average short‐term failure rate of 9% and 6.5%, respectively. Long‐term failure rates are low. One randomized trial failed to show improved success of anterior leak repairs with the use of a lumbar drain (LD) (95% with vs. 92% without; P = 0.2). In a large retrospective cohort of MCF lateral skull base repairs, perioperative LD use was not necessary in >94% of patients.

Conclusions

Spontaneous CSF leaks are associated with female gender, obesity, increased intracranial hypertension, and obstructive sleep apnea. Endoscopic repair of anterior skull base leaks and MCF or transmastoid approaches for lateral skull base leaks have a high success rate of repair. In most cases, intraoperative placement of lumbar drain did not appear to result in improved success rates for either anterior or lateral skull base leaks.

Level of Evidence

2a, Systematic Review.

Idiopathic intracranial hypertension: Contemporary review and implications for the otolaryngologist

OBJECTIVES

1) Review controversies pertaining to the pathophysiology, diagnosis, and treatment of idiopathic intracranial hypertension. 2) Discuss the evolving role of otolaryngologists in managing this disease and related disorders.

DATA SOURCES

Primary literature review, Centers for Disease Control and Prevention website, International Classification of Headache Disorders, Second Edition.

METHODS

A comprehensive review of the primary literature was performed from 1990 to 2016 utilizing keywords idiopathic intracranial hypertension, pseudotumor cerebri, benign intracranial hypertension, spontaneous cerebrospinal fluid leak, and encephalocele. Articles were included at the discretion of the authors based on novel and/or historical contributions to the literature.

RESULTS

The incidence of idiopathic intracranial hypertension is increasing along with the obesity epidemic. Undiagnosed patients may present to otolaryngologists with pulsatile tinnitus, dizziness, sleep apnea, and spontaneous cerebrospinal fluid leaks. Although diagnosis is predicated upon imaging findings and lumbar puncture, radiographic signs including empty sella, optic nerve dilation, and globe flattening may suggest the diagnosis. The most effective intervention is weight loss combined with acetazolamide. Surgery is reserved for severe or refractory symptoms and can be highly morbid. Otolaryngologists are increasingly responsible for managing a number of secondary disorders including cerebrospinal fluid rhinorrhea and otorrhea. Failure to manage intracranial hypertension may lead to adverse surgical outcomes.

CONCLUSIONS

The knowledge base for idiopathic intracranial hypertension has greatly expanded over the past 25 years. This disease is associated with a number of conditions directly relevant to otolaryngologists. A keen understanding of this disorder and its management may optimize outcomes in a growing number of patients. Laryngoscope, 128:248-256, 2018.

Analysis of Audiometric Outcomes following Combined Middle Cranial Fossa/Transmastoid Approaches for Spontaneous Cerebrospinal Fluid Otorrhea

Outcome Objectives

To (1) explore audiometric outcomes following use of a combined transmastoid/middle cranial fossa (TM-MCF) approach in the treatment of spontaneous cerebrospinal fluid (CSF) otorrhea and (2) determine the influence of dehiscence location and reconstructive methodology on audiometric outcomes.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

Adults with spontaneous CSF otorrhea were reviewed from 2007 to 2016 if they underwent combined TM-MCF. Definitive audiometric evaluations were performed at least 3 months postoperatively. The primary outcomes measures were pre- to postoperative changes in pure-tone average (PTA) and air-bone gap (ABG). Two subset analyses were performed for audiometric outcomes comparisons: first, patients with skull base dehiscences anterior to the ossicular chain were compared with those with posterior dehiscences. Second, patients undergoing skull base resurfacing plus abdominal fat graft mastoid obliteration (AFGMO) were compared with those undergoing resurfacing alone.

Results

A total of 28 patients and 31 ears were reviewed. There was 1 recurrent leak (3.5%). The cohort demonstrated significant improvement in mean postoperative ABG ( P = .008) but not PTA. On subset analysis, ears with posterior dehiscences demonstrated significant improvements in PTA ( P = .03) and ABG ( P = .05), while ears with anterior dehiscences did not. In addition, ears undergoing resurfacing plus AFGMO achieved significant improvements on all parameters ( P = .01). Only 3 of 15 ears undergoing resurfacing plus AFGMO experienced worsened postoperative hearing.

Conclusion

Use of the combined TM-MCF approach for treating spontaneous CSF otorrhea achieved good audiometric outcomes. Patients with skull base dehiscences posterior to the ossicles and those undergoing skull base resurfacing plus AFGMO achieved the most favorable results.

Spontaneous bilateral and concurrent cerebrospinal fluid otorrhoea: case presentation and literature review

BACKGROUND

Cerebrospinal fluid otorrhoea is a rare entity. Only a few cases of spontaneous bilateral cerebrospinal fluid otorrhoea have been reported. In all cases, there was a definite time interval between the two (left and right) presentations.

OBJECTIVES

To raise awareness and report on the very rare entity of bilateral spontaneous cerebrospinal fluid otorrhoea.

CASE REPORT

This paper reports the case of a bilateral, synchronous, spontaneous cerebrospinal fluid otorrhoea in a 44-year-old female. The patient had grommets surgically inserted on two separate occasions for treatment of otitis media with effusion, and received several courses of oral and topical antibiotics. Five years following the patient's initial presentation, a suspicion of concurrent bilateral cerebrospinal fluid otorrhoea was raised. The otorrhoea sample collected proved to be cerebrospinal fluid. Cross-sectional imaging revealed bilateral defects in the tegmen tympani of the skull base. She underwent staged middle fossa craniotomies to repair the defects.

CONCLUSION

Careful observation of the middle-ear fluid characteristics following myringotomy can allow for prompt diagnosis.