CSF Otorrhea Research Articles

The imaging appearances of stapical footplate fistula related to inner ear malformation

Objective: To summarize the HRCT and MRI appearances of stapical footplate fistula related to inner ear malformation (SFF-Re-IEM). Methods: The HRCT and MRI materials of 48 cases (53 ears) SFF-Re-IEM were retrospectively analyzed. Among them, 25 SFF-Re-IEM ears were confirmed by surgery. Their CT and MRI findings including associated IEM type, internal auditory canal (IAC) malformation, tympanic fluid, its density and signal features, and accompanied labyrinthitis were recorded. Results: Among 48 cases (53 ears) with SFF-Re-IEM, 17 ears with incomplete partition type Ⅰ, accounting for 32.1%, 13 ears with common cavity for 24.5%, 13 ears with cochlear aplasia for 24.5%, 7 ears with cochlear dysplasia Ⅱ for 13.2%, and 3 ears with Mondini for 5.7%,were found respectively. 94.3% of them were associated with a defect or dysplasia in the found of the IAC. They were divided into 4 types according to the intact of the stapical footplate and accompanied CSF otorrhea: 22 ears were diagnosed as the stapical footplate leaking, of them, 2 ears might come from the stapical footplate bony defect, 6 ears were from the stapical footplate hernia. 1 ear belonged to the peristapical footplate leaking. 30 ears with the isolated the stapical footplate hernia were another found. The bony defect in 2 ears with the stapical footplate bony defect were not presented on CT and MRI.The focal bony defect of the affected stapical footplate of 36 ears with the stapical footplate hernia were demonstrated, which presented the hemispherical protruding into the tympana, the soft-tissue density on CT, and CSF-like signal on the MR heaved-T2WI images. Among 22 ears with the stapical footplate leaking, their imaging appearances varied from the different amount of the leaking CSF. Besides the focal bony defects of the affected stapical footplates, there were much more CSF-like density or signal in the ipsilateral tympanic cavity in 17 affected ears connecting with the vestibule through the defect area. In the CSF leaking ears with less CSF leaking in 5 ears, the CSF-like cysts like SFH were shown on the stapical footplate defect area, but their outer edges were irregular, and the CSF-like signal scattering in the tympanic cavity did not connect with the protruding cysts at the stapical area. Conclusion: The variable appearances of the SFF-Re-IEM ears based on the different subtypes are its characteristic HRCT and MRI appearances. This is helpful for the SFF-Re-IEM diagnosing to grasp its imaging features.

Clinical diagnosis and treatment analysis of spontaneous cerebrospinal fluid otorrhoea

Objective:To investigate the clinical features, imaging findings, surgical methods， diagnostic and treatment experience of spontaneous cerebrospinal fluid otorrhoea. Methods:The clinical data of 11 patients with spontaneous cerebrospinal fluid otorrhoea treated surgically at our hospital from May 2018 to May 2023 were retrospectively analyzed. The medical data included medical history, imaging data, leak location, surgical repair method, treatment effect and postoperative follow-up. Results:Among the 11 surgical patients, 4 patients were initially diagnosed with secretory otitis media, 1 was initially diagnosed with purulent otitis media, and 5 patients had a history of meningitis or presented because meningitis as the initial diagnosis. There were 2 cases of cerebrospinal fluid leakage repaired through the ear canal pathway and 9 cases of cerebrospinal fluid leakage repaired through the mastoid pathway. During the operation, leaks were located in the stapes floor plate in 4 cases, sinus meningeal angle in 1 case, posterior cranial fossa combined with middle cranial fossa in 1 case, middle cranial fossa in 4 cases, and labyrinthine segment of the internal auditory canal and facial nerve canal in 1 case. Ten patient was successfully repaired, and another patient developed intracranial hypertension after surgery, with symptoms alleviated by a lateral ventriculoperitoneal shunt. Postoperative follow-up ranged from 6 months to 4 years, and there was no CSF otorrhoea and meningitis recurrence. Conclusion:The incidence of spontaneous cerebrospinal fluid otorrhea is low, the clinical symptoms are atypical, and the rate of delayed diagnosis or missed diagnosis and misdiagnosis is high. Surgery is currently the preferred treatment for spontaneous cerebrospinal fluid otorrhoea, and satisfactory results are usually achieved; During diagnosis and treatment, it is crucial to be vigilant for intracranial hypertension to prevent serious complications and irreversible damage.

Indirect Fistula: A New Terminology for Cerebrospinal Fluid Fistula With Different 'Apparent Origin' and 'Real Origin'.

Fistulas are abnormal communications between body cavities. They can occur between the CNSand the extracranial space, presenting clinically as CSFleaks. Due to the variety of features, multiple classifications have been implemented to better study this pathology. A systematic review was conducted using the Scopus, Medline, and Web of Science databases. Observational studies such as cohort studies, case reports, case series, cross-sectional studies, systematic reviews, and publications that assess the classification of CSF leaks were included. The systematic review identified 29 publications that met the required criteria for inclusion. Although the primary focus of most of these publications was not on classification, they briefly mentioned it. The included publications describe classifications according to etiology, exiting flow pressure, anatomic site, and some new classification proposals. Of the 29 included studies, 11 referred to the appearance of CSF rhinorrhea or otorrhea with no relationship between the cause or site of origin and the site of the CSF leak. However, none of these publications names this situation. These results clearly indicate that a term for this circumstance needs to be established; none of the previously listed publications provide a name for this condition. This systematic review aims to demonstrate the necessity of implementing a new term to describe CSF leaks where the 'apparent origin' does not correspond to the 'real origin.' The results show no existing term that considers such cases; therefore, we propose the term 'Indirect Fistula' to designate these cases.

Efficacy of endoscopic repair for CSF otorrhoea in children with recurrent meningitis due to incomplete partition type 1

ObjectiveTo review the efficacy of endoscopic management with or without cochlear implantation in a pediatric population presenting with recurrent meningitis due to inner ear incomplete partition type 1 (IP-1). Materials and methodsA multicentric report of 6 patients with a history of recurrent meningitis due to IP-1 was done. Radiological evaluation was performed to confirm the diagnosis. Transcanal endoscopic repair of the defect was performed in 3 cases, 2 cases underwent endoscope-assisted repair followed by cochlear implantation in the contralateral ear later, and 1 patient underwent endoscopic repair along with simultaneous cochlear implantation. ResultsRadiology confirmed the diagnosis and identified the site of the leak. A leak was detected in all cases from the stapes footplate. Two patients with unilateral deformity had a CSF-filled cyst protruding through a defect in the stapes footplate, and the rest of the four had a high flow CSF leak from the footplate. Five patients who underwent repair have had no further episodes of meningitis. One patient who received simultaneous implantation and repair developed postoperative meningitis managed successfully with antibiotics. ConclusionHearing loss due to inner ear deformity can be easily missed as a cause for recurrent meningitis, especially if unilateral. A high index of suspicion, audiological screening and radiology are essential to clinch the diagnosis. In such cases, a pure endoscopic or endoscopic assisted transcanal approach to repair CSF otorrhoea is an effective alternative to more radical procedures like subtotal petrosectomy with obliteration. In patients with bilateral profound hearing loss, simultaneous cochlear implantation and repair of the defect can be performed successfully.

Treatment of tegmen dehiscence using a middle fossa approach and autologous temporalis fascia graft: Outcomes from a single center

IntroductionAlthough bony defects of the tegmen surface are relatively common, the majority of dehiscences are asymptomatic. For those who experience symptoms, there is a wide spectrum of relatively benign manifestations such as hearing loss and otorrhea to potentially more serious but rare sequelae such as epilepsy and meningitis. Surgical management of tegmen dehiscences (TDs) can help prevent these symptoms. In this manuscript, we present one of the largest reported single team experiences of using a temporal craniotomy with middle cranial fossa approach and temporalis fascia graft in the treatment of tegmen defects. MethodsWe retrospectively reviewed every case of a TD surgically repaired by the same neurosurgeon/otolaryngologist team at Loyola University Medical Center from May 2015 to January 2022. In our chart review, we identified 44 patients with 48 cases of tegmen defect repair. We analyzed patient characteristics, operative details, and postoperative outcomes. Results44 patients met inclusion criteria for the presence of TD (mean age 55 years, 55% male, and average body mass index 35.6). 89% of these patients had no clear etiology for the dehiscence. Commonly reported symptoms were hearing loss (89%) and CSF otorrhea (82%). The least reported presenting signs and symptoms were seizures (5%) and meningitis (2%). Most defects were repaired with both temporalis fascial and calvarial bone grafts (63%), while a minority were treated with temporalis fascia only (33%), temporalis fascia with muscle (2%), or fascia lata (2%). Every patient in our sample experienced resolution of CSF otorrhea after tegmen repair and 81% of the sample reported subjective hearing improvements after surgery. 6% of our sample had post-operative infections and 8% of patients underwent repeat unilateral surgery for a surgical complication. ConclusionCraniotomy for middle fossa approach using autologous temporalis fascial grafts is a safe and effective method for the treatment of TD. These procedures should be performed by experienced and multidisciplinary teams.

Management of Meningitis Due to Cystic Cochleovestibular Malformation: a Stitch in Time.

Spontaneous CSF otorrhea alludes to those cases which have no known etiology like traumatic, iatrogenic, neoplastic or infectious. The presentation of the patient depends on the anatomical integrity of the eustachian tube as well as the tympanic membrane. Children with certain congenital inner ear malformations, including incomplete partition deformity, show a higher incidence of spontaneous CSF leaks and the resultant meningitis. Cystic vestibulocochlear deformity accounts for approximately 20% of inner ear malformations. In this case report, we discuss a child who presented with first episode of meningitis and with the help of thorough clinical otorhinolaryngological examination and radiology, was diagnosed with a congenital ear anomaly. With this paper, we stress upon the importance of keeping an open mind regarding the differential diagnosis of any condition, and the value of timely intervention.

Otological Manifestations in Head Injury: Experience from a Tertiary Academic Centre.

Head injuries are most commonly associated with serious otolaryngological involvement. This study was done to identify the otological manifestations and its sequelae among patients with head injury. A prospective study conducted in a tertiary care centre, among patients attending the Emergency medicine, Otorhinolaryngology and Neurosurgery departments from August 2017-July 2018 with head injury and associated otological manifestations. They were examined within 48hours of admission and followed up for two months. There were 243 patients with head injury, among which 201 were male and 42 were female patients. Majority of them (44.8%) were between 21 and 40years of age. Road traffic accidents (RTA) was the commonest cause of head injury occurring in 91.8% patients. Among them, 58 patients (23.9%) had otological manifestations, the most common symptom and sign being ear bleed (72.4%) and temporal bone fracture (46.6%) respectively followed by facial nerve palsy (24.1%) and hearing loss (22.4%). Temporal bone fracture had statistically significant association with ear bleed, hearing loss, facial palsy and CSF otorrhoea (p = 0.0001) and tympanic perforation (p = 0.03). Otological involvement occurred in almost one fourth of the patients with head injury, the most common serious complication being temporal bone fractures which was diagnosed in almost half of this population followed by facial nerve palsy. Ear bleed, hearing loss and CSF otorrhea are significant indicators of underlying temporal bone fractures, necessitating early ENT evaluation and HRCT temporal bones for timely detection and prevention of disabling otological complications.

Exclusive endoscopic transcanal approach to lateral skull base lesions: Institutional experience of 3 cases

IntroductionMajority of petrous bone and lateral skull base pathologies are benign in nature. The complex anatomy usually warrants an extensive approach with associated morbidity. Case summaryTwo cases of petrous bone cholesteatoma (1 congenital cholesteatoma with facial palsy and 1 acquired cholesteatoma) and a case of glomus tympanicum were treated with exclusive endoscopic transcanal approach. The cases of petrous cholesteatoma were addressed with trans-promontorial and infra-cochlear approaches. The mean operative time was approximately 140 min. No CSF otorrhoea was noticed in the post-operative period. The average period of hospital stay was 3.7 days. ConclusionIn the subset of cases with limited benign disease an endoscopic trans-canal approach is a better alternative to an external approach. It decreases operative time, blood loss, chance of meningitis, morbidity and hospital stay. The lack of depth perception is a major hurdle which can be come over by experience in endoscopic middle ear surgery. This approach can create direct access to cochlea/petrous apex/internal auditory canal (IAC)/Supra-geniculate ganglion region.

Risk factors associated with CSF leakage and complications after retrosigmoid surgery

ObjectiveCerebrospinal fluid (CSF) leakage is a common complication of retrosigmoid surgery that may cause dehiscence of the surgical wound or infection. We sought to identify risk factors associated with CSF leakage and accompanying complications. MethodsCharts from patients who underwent a retrosigmoid approach surgery at Ramathibodi Hospital between 2007 and 2019 were retrospectively reviewed. Data from patients who did and did not have CSF leakage were compared to define the patient characteristics, factors related to CSF leakage, types of leakage, and complications encountered after CSF leakage. Multiple logistic regression analyses were conducted to determine the variable factors associated with CSF leakage and accompanying complications. ResultsCSF leakage occurred in 40 of 286 patients (14%). The risk factors associated with CSF leakage were age and body mass index (BMI). Patients with stage I obesity and stage II obesity had a significantly increased risk of CSF leakage. Subgroup analysis revealed that hydrocephalus and radiation were risk factors for pseudomeningocele. Wound dehiscence and CSF wound leakage were associated with pseudomeningocele. All types of CSF leakage, i.e., pseudomeningocele, wound leakage, CSF rhinorrhea, and CSF otorrhea, were risk factors for wound infection and meningitis. ConclusionsAge and BMI were related to CSF leakage. Specifically, younger patients were more likely to have CSF leakage and obese patients had higher CSF leakage rates compared with patients with a normal BMI. Wound infection and meningitis frequently occurred when these complications occurred.

Prevalence of Spontaneous Asymptomatic Facial Nerve Canal Meningoceles: A Retrospective Review.

The prevalence of patent facial nerve canals and meningoceles along the facial nerve course is unknown. This study aimed to assess the frequency of such findings in asymptomatic patients. A retrospective review was completed of patients with high-resolution MR imaging of the temporal bone whose clinical presentations were unrelated to facial nerve pathology. Facial nerve canals were assessed for the presence of fluid along each segment and meningoceles within either the labyrinthine segment (fluid-filled distention, ≥1.0-mm diameter) or geniculate ganglion fossa (fluid-filled distention, ≥2.0-mm diameter). If a meningocele was noted, images were assessed for signs of CSF leak. Of 204 patients, 36 (17.6%) had fluid in the labyrinthine segment of the facial nerve canal and 40 (19.6%) had fluid in the geniculate ganglion fossa. Five (2.5%) had meningoceles of the geniculate ganglion fossa; no meningoceles of the labyrinthine segment of the canal were observed. No significant difference was observed in the ages of patients with fluid in the labyrinthine segment of the canal or geniculate ganglion compared with those without fluid (P = .177 and P = .896, respectively). Of the patients with a meningocele, one had a partially empty sella and none had imaging evidence of CSF leak or intracranial hypotension. Fluid within the labyrinthine and geniculate segments of the facial nerve canal is relatively common. Geniculate ganglion meningoceles are also observed, though less frequently. Such findings should be considered of little clinical importance without radiologic evidence of CSF otorrhea, meningitis, or facial nerve palsy.

Prognostic factors in severe head injury: A Clinico radiological study

Background: Traumatic Brain injuries (TBI) are a real social problem with an upward trend worldwide. For these reason prognostic factors in head injury are of major importance to all surgeons who treat patients with severe head injury especially for countries like India for better targeting of limited health care resources and implementation of specific methods of treatment to patients and to determine the incidence of age, sex, distribution, etiological factors, clinical presentation, neurologically assessment and mode of head injuries with particular reference to severe head injury. Methods: This study was conducted in the Neurosurgery unit of Surgery department of Index Medical College, Hospital & Research Centre, Indore from Jan 2016 to Jun 2017. In this study 150 patients of severe head injury were included These patients were evaluated for the severity of the head injury (GCS), clinical presentation, X-rays, C T scan/MRI, early complication (Hypoxia and Hypotension) and Post traumatic seizures. Result: In all 150 patients with severe head injury were identified shows that road traffic accident is the main cause of head injury in majority of cases with male preponderance. Incidence of head injury due to fall from height was nearly equal in both sex. It was found that maximum number of head injury patients belonged to the age group of 21-40 years (78%) in male. Maximum number of head injury was caused due to road traffic accidents (72%). Conclusion: Males are more prone to head injury due to road traffic accident with maximum in two –wheeler accidents as most of the patients were not wearing helmets. CSF otorrhoea was more common than CSF rhinorrhoea. Extradural hematoma was more common in tempero-parietal region and Coup injuries were more common than contre coup injuries. Types of trauma and brain lesion, hypoxia and hypotension, hyperglycemia and early post traumatic seizures are the important prognostic factors.

Pretemporal trans-Meckel's cave transtentorial approach for large petroclival meningiomas.

OBJECTIVE Despite the advances in skull base techniques, large petroclival meningiomas (PCMs) still pose a challenge to neurosurgeons. The authors' objective of this study was to describe a pretemporal trans-Meckel's cave transtentorial approach for large PCMs and to report the surgical outcomes. METHODS From 2014 to 2017, patients harboring large PCMs (> 3 cm) and undergoing their first resection via this procedure at the authors' institute were included. In combination with pretemporal transcavernous and anterior transpetrosal approaches, the trans-Meckel's cave transtentorial route was created. Surgical details are described and a video demonstrating the procedure is included. Retrospective review of the medical records and imaging studies was performed. RESULTS A total of 18 patients (6 men and 12 women) were included in this study, with mean age of 53 years. The mean sizes of the preoperative and postoperative PCMs were 4.36 cm × 4.09 cm × 4.13 cm (length × width × height) and 0.83 cm × 1.08 cm × 0.75 cm, respectively. Gross-total removal was performed in 7 patients, near-total removal (> 95%) in 7 patients, and subtotal removal in 4 patients (> 90% in 3 patients and > 85% in 1 patient). There were no surgical deaths or patients with postoperative hemiplegia. Surgical complications included transient cranial nerve (CN) III palsy (all patients, resolved in 3 months), transient CN VI palsy (2 patients), CN IV palsy (3 patients, partial recovery), hydrocephalus (3 patients), and CSF otorrhea (1 patient). Temporal lobe retraction-related neurological deficits were not observed. CONCLUSIONS A pretemporal trans-Meckel's cave transtentorial approach offers large surgical exposure and multiple trajectories to the suprasellar, interpeduncular, prepontine, and upper-half clival regions without overt traction, which is mandatory to remove large PCMs. To unlock Meckel's cave where a large PCM lies abutting the cave, pretemporal transcavernous and anterior transpetrosal approaches are prerequisites to create adequate exposure for the final trans-Meckel's cave step.

Bilateral temporal bone fractures: a case report

<p>Bilateral temporal bone fractures are rare; accounting for 9% to 20% of cases of temporal bone fractures. Clinical manifestations include hearing loss, facial paralysis, CSF otorhinorrhea and dizziness. This is a case report of a patient who presented with bilateral temporal bone fractures. This is a report of a 23-yr-old male who sustained bilateral temporal bone fractures and presented 18 days later with complaints of watery discharge from left ear and nose, bilateral profound hearing loss and facial weakness on the right side. Pure tone audiometry revealed bilateral profound sensori-neural hearing loss. CT temporal bones & MRI scans of brain were done to assess the extent of injuries. The patient underwent left CSF otorrhea repair, as the CSF leak was active and not responding to conservative management. One week later, the patient underwent right facial nerve decompression. The patient could not afford a cochlear implant (CI) in the right ear at the same sitting, however, implantation was advised as soon as possible because of the risk of cochlear ossification. The transcochlear approach was used to seal the CSF leak from the oval and round windows on the left side. The facial nerve was decompressed on the right side. The House-Brackmann grade improved from Grade V to grade III at last follow-up. Patients with bilateral temporal bone fractures require prompt assessment and management to decrease the risk of complications such as meningitis, permanent facial paralysis or hearing loss. </p>

Diagnosis and management of spontaneous cerebral spinal fluid otorrhea

Spontaneous cerebral spinal fluidotorrhea (SCSFO) is a type of CSF otorrhea without obvious causes including previous trauma, surgery, infection or neoplasm. The etiology of SCSFO remains unclear, the diagnosis can be overlooked because of the untypical clinical features. In this paper, we reviewed etiology, clinical features, diagnosis and therapy of SCSFO from recent relative literatures.

MVD for trigeminal neuralgia; neuralgia revisited with review of literature

<p class="abstract"><strong>Background:</strong> <span lang="EN-IN">Trigeminal neuralgia (TN) s an uncommon facial pain syndrome. It is commonly characterized by sudden onset of an attack of intense electric shock like facial pain localized along the sensory distribution of the ninth cranial nerve. Although many patients respond to the medical line of treatment but when PTS symptoms become intractable and could not tolerate the medications have to go for surgical decompression. Our study aims to review about micro vascular decompression for trigeminal neuralgia and its outcome along with the review of literature. </span></p><p class="abstract"><strong>Methods:</strong> <span lang="EN-IN">It is a retrospective study conducted on 40 cases who were diagnosed with TN. between the period of July 2009 to July 2015. MVD has been performed on all the patients. Demographic data, clinical presentation, surgical findings, complications and long term follow-up were reviewed. </span></p><p class="abstract"><strong>Results:</strong> <span lang="EN-IN">The median age of onset of TN is 50.4 years divided into five age groups ranging from 24 to 89 years with female preponderance showing 65.5% as compared to males. The distribution of location was in the ratio of right to left is 1.5:1. There was no mortality is seen in the study. 3 patients among them study population had complications 3 patients had facial hyposthesia, 1 patient had V3 paresis and 1 patient had CSF otorrhoea which got settled with drainage LP. All the patients had satisfactory improvement except one patient who had persistent pain. </span></p><p class="abstract"><strong>Conclusions:</strong> <span lang="EN-IN">To conclude micro vascular decompression (MVD) is the surgical procedure of choice for the treatment of medically refractory TN who is fit for surgery. Of all the currently available surgical methods MVD provides the highest rate of long term satisfaction for the patients and offers the lowest rate of pain recurrence.</span></p>

Cerebrospinal fluid otorrhea after head injury (case report).

This report presents a case of CSF otorrhea after head injury in a boy commencing after myringotomy. We believe it to be the first documented one in the Indonesian literature.

Surgical treatment of lateral skull base lesions and reconstruction of the skull base: a report of 20 cases

Objective: To investigate the surgical treatment and related experience of lateral skull base lesions.Methods: In a retrospective, clinical data analysis of 20 patients with lateral skull base diseases, 11 cases with temporal bone space-occupying lesions and intracranial invasion were treated by translabyrinthine surgery, mastoid cavity drainage, or transmastoid surgery to remove the lesion; two cases of cholesteatoma with destruction of tympanic cavity and tympanic sinus canopy with intracranial invasion were treated by extended radical mastoidectomy; seven cases with lateral skull base bone destruction with cerebrospinal fluid otorrhea caused by trauma and deformity were treated by translabyrinth and transmastoid repair.Results: Eleven cases with temporal bone space occupying lesions were resected completely and were without recurrence after surgery. Two cases with intracranial infection secondary to cholesteatoma were rapidly relieved of symptoms without recurrence after radical mastoidectomy. The remaining seven cases of CSF otorrhea included two cases of Mondini malformation and five cases of temporal bone fracture. The leak was stemmed in all seven cases after surgery.Conclusion: Surgery is the main therapeutic option for the treatment of lateral skull base diseases. The surgical approach and the type of skull base reconstruction should be selected on an individual case-by-case basis.

Lateral Skull Base Attenuation in Superior Semicircular Canal Dehiscence and Spontaneous Cerebrospinal Fluid Otorrhea.

(1) To quantitatively assess the lateral skull base thickness in patients with superior semicircular canal dehiscense (SSCD) using a standardized and validated radiographic measure and to compare it with that of a population with spontaneous cerebrospinal fluid otorrhea (CSFO). (2) To analyze demographic and clinical factors associated with skull base thickness in the SSCD group. Case series with chart review. Tertiary neurotologic referral center. Based on computed tomography imaging of the tegmen, mean skull base thickness was calculated for 16 patients with radiographic and clinical SSCD. Similar measures were performed in 4 comparison groups consisting of adults with spontaneous CSFO (n = 33), as well as 3 control groups recruited from our adult cochlear implant database: 30 obese controls (body mass index [BMI] >30 kg/m(2)), 11 overweight controls (BMI, 25-30 kg/m(2)), and 20 normal weight controls (BMI <25 kg/m(2)). The SSCD group had a significantly lower mean BMI (28.6 kg/m(2)) than the spontaneous CSFO group (37.7 kg/m(2); P = .0007). The mean skull base thickness of SSCD patients was 17% thinner than that of the CSFO group, 31% thinner vs obese controls, 49% thinner vs overweight controls, and 45% thinner vs normal weight controls. These differences were all statistically significant (P < .05). Patients with SSCD have a marked thinning of the lateral skull base, more so than patients with spontaneous CSF otorrhea and control groups with different BMIs. Skull base attenuation in SSCD patients did not correlate with BMI.

Cholesteatomas of the Petrous Apex – Report of 5 Cases and their Management

Cholesteatomas are commonly encountered in the middle ear as a consequence of chronic infection. Large cholesteatomas of the petrous apex are much less common and may be congenital in origin. We present 5 cases of extremely large petroux apex cholesteatomas. Three patients presented with CSF otorrhea. Two patients presented with facial paralysis. One patient also had a temporal encephalocele. All patients had comprehensive imaging studies with both CT & MR scans. We highlight the features that differentiate cholesteatoma from other entities such as cholesterol granuloma. These features allowed us to make a precise diagnosis of cholesteatoma in every case before surgery. The lesions had a tendency to relentlessly destroy every tissue in the their vicinity, including neurovascular structures, bone, cochlea, labyrinth, and dura. All of the patients underwent surgical resection; the cholesteatomas were approached from either the mastoid alone or in combination with a small temporal craniotomy.The CSF otorrhea was stopped in all cases and the temporal encephalocele was successfully repaired by combined approach involving both craniotomy & tympanomastoidectomy. Facial nerve palsy improved in one patient and did not improve in the other. Our presentation will include detailed radiological imaging and details of the surgical procedure. In summary, we will show the clinical features, radiological imaging, and surgical details of petrous apex cholesteatomas. We also emphasize their chronic, indolence course until they present with a serious symptom such as facial nerve paralysis or CSF otorrhea.

Spontaneous defects between the mastoid and posterior cranial fossa

Conclusions Spontaneous defects between the mastoid and the posterior cranial fossa are exceedingly rare. Patients with these lesions may have a lower BMI compared to those with middle cranial fossa encephaloceles, but are otherwise demographically similar. This study recommends repair via a transtemporal approach to allow for examination of the entire posterior face of the temporal bone. Objective To describe cases of spontaneous posterior cranial fossa defects. Methods This study reviewed all cases of spontaneous posterior fossa defects presenting to a tertiary referral center over the last decade and described clinical presentation, imaging, operative findings, and outcomes. We also compared these lesions to those previously reported in the literature as well as the more common spontaneous encephaloceles of the middle cranial fossa.Results This study identified five cases with a mean age of 61.4 years, female-to-male ratio of 4:1, and a mean BMI of 31. Three cases presented with spontaneous pneumocephalus, one with CSF otorrhea, and one as an incidental imaging finding. Four defects were found medial to the sigmoid sinus and one was in the lateral retrosigmoid air cells.