CSF Otorrhea Research Articles

Management of Cerebrospinal Fluid Leak following Posterior Cranial Fossa Surgery.

Objective:Cerebrospinal fluid leakage remains a significant cause of morbidity following posterior fossa surgery, and its treatment remains a difficult problem. The aim of the study was to propose a treatment algorithm for its management.Methods:A retrospective, single-center study was conducted on 147 patients who underwent elective posterior fossa surgery for a variety of diseases. Patients with post operative CSF leakage had either been treated initially with conservative measures including re-suturing of the wound, with CSF lumbar drainage to be employed in case the CSF leakage didn’t stop, or the initial intervention was the institution of CSF lumbar drainage simultaneously with conservative measures. VP (ventriculo-peritoneal) shunt was done in patients with gross hydrocephalus on postoperative CT brain.Results:There were 25 (17%) cases of CSF leakage, including 24 incisional CSF leaks and one case of CSF otorrhea. In eight patients with incisional CSF leakage treated initially with conservative measures including re-suturing of the wound, CSF leakage stopped in only two cases. CSF lumbar drainage instituted later on in six cases with persistent leakage stopped the CSF leakage. In fourteen patients managed initially with re-suturing of the wound and concomitant CSF lumbar drainage, CSF leakage settled in all the cases. Two patients with gross hydrocephalus on post operative CT were managed successfully with VP shunt. Re-suturing of the wound with concomitant CSF lumbar drainage was found to be significantly associated (p=0.003) with the stoppage of CSF leakage, and the settlement of meningitis (p= 0.014).Conclusion:Incisional CSF leaks after posterior fossa surgery should be managed with re-suturing of the wound and concomitant CSF lumbar drainage, instead of an initial trial of conservative therapy alone.

Spontaneous CSF otorrhea in cases of Mondini's dysplasia: a rare cause of recurrent bacterial meningitis

Inner ear anomaly is rare developmental anomaly with Mondini’s dysplasia being the most common. The perilymphatic fistula cause due to high pressure condition in anomalous inner ear result into CSF otorrhea which become a tract for bacteria to reach central nervous system and cause recurrent meningitis. We are presenting 3 cases of Mondini’s dyaplasia which had CSF leaking into middle ear cleft which was diagnosed with HRCT of temporal bone with cisternography and MRI cisternography and were managed successfully with surgical repair by trans-mastoid approach.

The lower border of the zygomatic arch could be a better landmark for the middle fossa dura: Cadaveric dissection study

BackgroundDural injury and CSF otorrhea is a serious complication during mastoidectomy especially in low level dura. ObjectivesAim of the study is to determine a reliable landmark for the middle fossa dura to minimize risk of dural injury and CSF otorrhea during mastoidectomy. By answering the question which is considered as a more fixed landmark for the dura; the supramastoid crest or the lower border of the zygomatic arch? MethodsA cadaveric study was done on 204 temporal bone specimens in the temporal bone lab at the Ain Shams University Specialized Hospital.A correlation between the level of the supramastoid crest and the level of the zygomatic arch was done.A correlation between the level of the dura and the level of the supramastoid crest in the area of mastoid antrum was done.A correlation between the level of the dura and the level of the zygomatic arch was done. ResultsIn 20.6% of specimens, the dura lies at a lower level than the level of the supramastoid crest but in 2.9% of specimens the dura lies at a lower level than the lower border of the zygomatic arch. ConclusionIt is better to consider the lower border of the zygomatic arch as a reliable landmark of the middle fossa dura in the area of the antrum than to consider the supramastoid crest as a landmark for the dura. It is better to consider imaginary line directed posteriorly from the lower border of the zygomatic arch as a superior limb of the Macewen triangle.

Lateral petrosectomy with obliteration cavity for spontaneous cerebrospinal otorrhea in children

PurposeThe most common causative factors of CSF otorrhea in children are injuries and congenital abnormalities of the temporal bone. Spontaneous CSF leak as a consequence of congenital temporal bone defects may result in recurrent meningitis. Diagnosis and management of such an entity are particularly difficult in early childhood. Materials and methodsThe aim of this study was to investigate clinical features and to discuss possible methods of treatment of spontaneous CSF otorrhea in children. ResultsSevere unilateral sensorineural hearing loss or total deafness was found in children with CSF otorrhea. CT and MRI of the temporal bones revealed dehiscences in the walls of the tympanic cavity and defects of the inner ear, which were confirmed intraoperatively. Lateral petrosectomy and closure of the fistula with muscle tissue and fat obliteration cavity were performed. The children remain free of otorrhea and recurrences of meningitis. ConclusionThe diagnosis of spontaneous otorrhea in children is based on the severe unilateral sensorineural hearing loss and presence of CSF in the middlę ear cavity. It may be successfully treated by means of lateral petrosectomy with obliteration of the vestibule with muscle tissue and tympanic cavity with fat tissue.

Temporal Bone Encephalocele Repair – Our Experience

Background: Presentations of encephalocele of temporal bone can range from an incidental finding in asymptomatic patient to a life threating meningitis in a CSF otorrhea patient. Literature is replete with different surgical techniques for management of these varied patients. Autologous materials like fat, muscle, fascia, bone, cartilage and alloplasts like bone cement etc. have been used to repair the tegmen defects. The main aim of our study was to review all the cases of temporal bone encephaloceles surgically managed in our institution. We present the etiologies, approaches along with the tegmen repair technique used in our series.

Pulse-Synchronous Tinnitus and Sigmoid Sinus Wall Anomalies

Describe the clinical features of a population of patients with sinus wall anomalies (SWA) and pulse-synchronous tinnitus (PST). Retrospective review. Tertiary referral center. Patients with PST and SWA undergoing surgical management between 2007 and 2012. Transmastoid sinus wall reconstruction. Age, sex, BMI, and postoperative course. Two-tailed t tests (p ≤ 0.05) compared BMI and age of the study group with negative and positive controls. Thirteen patients presented with sigmoid sinus diverticulum (39.4%) and 20 (60.6%) with sinus wall dehiscence. Thirty ears were successfully treated with surgery (responders), and 3 were not (nonresponders). Responders' mean age was 38 years, with 26 female patients (92.9%) and 2 male (7.1%). BMI of responders compared with nonresponders did not differ significantly (35.5 versus 33.4 kg/m2, p = 0.08). BMI of responders was elevated compared with an asymptomatic control group (35.5 versus 27.4 kg/m2, p < 0.0001). BMI of responders did not differ significantly compared with a cohort of patients with spontaneous CSF otorrhea and temporal bone encephaloceles (35.5 versus 40.7 kg/m2, p = 0.17). The patients in this study had elevated BMI and were more likely to be female. This patient population strongly resembles that of patients with IIH, suggesting the possibility that SWA may be a cause of PST in some patients with IIH. Illustrative cases supporting this hypothesis are presented.

Is posttraumatic cerebrospinal fluid fistula a predictor of posttraumatic meningitis? A US Nationwide Inpatient Sample database study

Various factors have been reported in literature to be associated with the development of posttraumatic meningitis. There is a paucity of data regarding skull fractures and facial fractures leading to CSF leaks and their association with the development of meningitis. The primary objective of this study was to analyze the US Nationwide Inpatient Sample (NIS) database to elucidate the factors associated with the development of posttraumatic meningitis. A secondary goal was to analyze the overall hospitalization cost related to posttraumatic meningitis and factors associated with that cost. The NIS database was analyzed to identify patients admitted to hospitals with a diagnosis of head injury from 2005 through 2009. This data set was analyzed to assess the relationship of various clinical parameters that may affect the development of posttraumatic meningitis using binary logistic regression models. Additionally, the overall hospitalization cost for the head injury patients who did not undergo any neurosurgical intervention was further categorized into quartile groups, and a regression model was created to analyze various factors responsible for escalating the overall cost of the hospital stay. A total of 382,267 inpatient admissions for head injury were analyzed for the 2005-2009 period. Meningitis was reported in 0.2% of these cases (708 cases). Closed skull base fractures, open skull base fractures, cranial vault fractures, and maxillofacial fractures were reported in 20,524 (5.4%), 1089 (0.3%), 5064 (1.3%), and 88,649 (23.2%) patients, respectively. Among these patients with fractures, meningitis was noted in 0.17%, 0.18%, 0.05%, and 0.10% admissions, respectively. Cerebrospinal fluid rhinorrhea was reported in 453 head injury patients (0.1%) and CSF otorrhea in 582 (0.2%). Of the patients reported to have CSF rhinorrhea, 35 (7.7%) developed meningitis, whereas in the cohort with CSF otorrhea, 15 patients (2.6%) developed meningitis. Cerebrospinal fluid rhinorrhea (p < 0.001, OR 22.8, 95% CI 15.6-33.3), CSF otorrhea (p < 0.001, OR 9.2, 95% CI 5.2-16.09), and major neurosurgical procedures (p < 0.001, OR 5.6, 95% CI 4.8-6.5) were independent predictors of meningitis. Further, CSF rhinorrhea (p < 0.001, OR 2.0, 95% CI 1.6-2.7), CSF otorrhea (p < 0.001, OR 2.3, 95% CI 1.9-2.7), and posttraumatic meningitis (p < 0.001, OR 3.1, 95% CI 2.5-3.8) were independent factors responsible for escalating the cost of head injury in cases not requiring any major neurosurgical intervention. Cerebrospinal fluid rhinorrhea and CSF otorrhea are independent predictors of posttraumatic meningitis. Furthermore, meningitis and CSF fistulas may independently lead to significantly increased cost of hospitalization in head injury patients not undergoing any major neurosurgical intervention.

Repair of middle fossa cerebrospinal fluid leaks using a novel combination of materials: technical note

Methods for repairing middle fossa CSF (MFCSF) leaks have varied and yielded mixed results. The objective of this study was to evaluate the safety and durability of the authors' repair technique using a novel combination of 3 synthetic materials. The authors performed a retrospective case review of patients treated for CSF leaks between January 2009 and September 2011. Eight patients were found to have undergone middle fossa craniotomies for CSF leaks. Inclusion criteria for the study included age greater than 18 years, neuroimaging-documented temporal bone defect, and symptoms consistent with CSF leaks or gross CSF otorrhea. Seven patients, 3 men and 4 women, met the inclusion criteria, and their charts were reviewed. Hydroxyapatite cement, collagen-based dural substitute matrix, and polyethylene glycol hydrogel sealant were used in all patients for the repair. In all patients the MFCSF leaks were successfully repaired. Initial presenting symptoms included CSF otorrhea in 4 patients (57.1%), hearing loss in 3 (42.9%), and CSF rhinorrhea in 1 (14.3%). The mean follow-up duration was 12 months (range 5-33 months). In 1 patient an epidural hematoma developed at the operative site on postoperative Day 2, and in another patient a superficial wound dehiscence occurred on postoperative Day 48. During the follow-up period, the authors found no evidence of wound infections, neurovascular damage, or CSF leakage requiring reoperation. The middle fossa approach involving a combination of hydroxyapatite cement, collagen-based dural substitute matrix, and polyethylene glycol hydrogel sealant is a safe, effective method for repairing MFCSF leaks. The combination of synthetic materials provides an alternative to existing materials for skull base surgeons.

髄膜炎を発症した特発性耳性髄液漏の2症例

We report on two cases of spontaneous CSF otorrhea, which were considered to have been caused by enlarged arachnoid granulation with bone erosion of the posterior fossa. Both cases visited us complaining of severe headache, due to bacterial meningitis. In the first patient, a 68-year-old male, a high resolution CT scan showed a bony defect in the posterior fossa plate in the right temporal bone, where CSF leakage was confirmed during the operation. In the second patient, a 54-year-old female, a bony defect was located in the posterior fossa in the left temporal bone. In both cases, the bony defects were repaired by occlusion with the pedicled temporal muscles after the meningitis had been treated. CSF otorrhea disappeared after the surgery, and has not recurred during the postoperative observation period of 1 to 3 years.

Otolicuorrea espontánea en el adulto. Presentación de dos casos y revisión de la literatura

Spontaneous cerebrospinal fluid otorrhea is a relatively rare entity and can be easily missed in adults. Every adult older than 50 years with a negative history of otologic disease who has recurrent serous otitis media should be evaluated for this pathology. Meningitis is the most serious complication, so there is no doubt that the condition needs immediate attention and correction. We present two patients who were diagnosed with spontaneous CSF otorrhea and make a review of what is reported about this topic. Surgical repair is mandatory to seal these nontraumatic CSF leaks. There are two main surgical approaches, the middle fossa craniotomy and the transmastoid approach. A multilayered closure technique in which autologous and artificial materials are combined is considered to result in the highest rate of success.

Facial diplegia and deafness following a fall

A 45-year-old man presented to the emergency department (ED) after falling down two flights of stairs. He had bilateral raccoon eyes, subconjunctival haemorrhages and CSF otorrhoea suggestive of skull base fracture (SBF). Although he had difficulty speaking and responded inappropriately, giving the impression of mixed dysphasia, written communication was normal, and he complained of deafness and dizziness. Facial motion was barely perceptible and complete eye closure was not possible, consistent with grade 5 facial palsies on the House-Brackmann facial nerve grading system. Bell’s phenomena (Fig. 1) and dysarthrophonia secondary to facial weakness were marked. He was also mildly ataxic. Computed tomography (CT) imaging confirmed extensive SBF and audiometric testing confirmed bilateral deafness. High-resolution axial petrous temporal bone CT (Fig. 2) demonstrated fractures involving the facial canals. The right-sided fracture traversed the fundus of the internal auditory canal, likely transecting the cochlear nerve, and the left-sided fracture involved the otic capsule, likely disrupting auditory and vestibular function. Fig. 1 a A 45-year-old man with facial diplegia. b Patient attempting to close both eyes producing bilateral Bell’s phenomenon. c Magnification of b demonstrating marked bilateral Bell’s phenomenon (more pronounced on the right side) Fig. 2 Right and left axial petrous temporal bone CT. Right axial CT shows a medial subtype of horizontal temporal bone fracture. There is a fracture of the posterior petrous surface (white arrow) extending anteriorly through the fundus of the internal auditory ... Post-traumatic facial nerve palsy complicates 1.5% of SBFs involving the temporal bones [1]. Petrous temporal bone fractures may disrupt the facial nerve, membranous labyrinth and inner ear. While cranial nerves seven and eight may be injured by petrous temporal bone fractures, concomitant bilateral facial weakness and deafness in this setting is extremely rare [2]. Most post-traumatic facial nerve injuries recover with conservative management and time [3, 4]. This case illustrates how bilateral facial weakness and deafness may be mistaken for mixed dysphasia and highlights the need to consider it in patients with apparent speech disturbances in the ED.

A study of temporal bone fractures

Many young adults are now killed and injured in accidents than from another causes. More than 75% of these injuries are to the head, and the ear being the most frequently injured sensory organ of the body. Temporal bone or basilar skull fractures are extremely common in any head injury. Injuries to the temporal bone may be considered in three groups: Those affecting the external auditory meatus (extralabyranthine fractures), those largely affecting middle ear cleft (tympanolabyranthine) and those affecting the internal ear (labyrinthine fractures). Many injuries, however, involve all these structures.The sudden onset of facial paralysis, vertigo and hearing impairment after a head injury is a matter of great concern for the patients and clinicians. Presence of cerebrospinal fluid leak (CSF Otorrhoea) can be a challenge for both the neurosurgeons and otologists. We hereby present 86 patients of temporal bone fractures who presented in the departments of emergency, Neurosurgery or ENT of Himalayan Institute of Medical Sciences, Dehradun during last 10 years (1996-2006).

Spontaneous closure of traumatic CSF otorrhoea following conservative management

We present a 40 year-old male who sustained a head injury with left cerebrospinal fluid otorrhoea following a road traffic accident. Plain radiograph revealed a defect in the temporal bone extending in to the tympanomastoid area. Patient was managed conservatively with closure of the fistula and resolution of the leakage within 8 days after injury. We report this to further buttress the role of conservative management in CSF fistula. African Journal of Health Sciences Vol. 13 (3-4) 2006: pp. 78-80

Cochlear implantation in infants less than 12 months of age

Infants are diagnosed with severe to profound hearing loss at an earlier age due to the advent of universal newborn hearing screening. This offers the opportunity to provide intervention in the form of cochlear implantation at an earlier age than was previously possible. The purpose of this investigation is to evaluate the risk of cochlear implant surgery in children less than 12 months of age. Retrospective review of children who underwent cochlear implantation before 12 months of age. Patients were identified from a database of pediatric cochlear implant patients at a tertiary care center. All patients were diagnosed with severe to profound hearing loss by otoacoustic emission and auditory brainstem response. Follow-up ranged from 2 months to 5 years. Fourteen of 15 patients had full insertions of the electrode hardware. Less than full insertion and post-operative CSF otorrhea occurred in one patient with severe cochlear abnormalities. There were no other perioperative surgical complications. The average speech detection threshold was 27.6 dB (20-45 dB) at approximately 1-3 months post-stimulation and 25 dB (15-30 dB) at approximately 5-7 months. In our experience, we feel cochlear implantation is safe for infants as young as 6 months of age. The current standard at our institution is to implant by 7 months of age for prelingual deafness as opposed to waiting additional time until 12 months of age before the brain is presented with speech.

Otogenic Tension Pneumocephalus Caused by Therapeutic Lumbar Csf Drainage for Post-Traumatic Hydrocephalus: A Case Report

Tension pneumocephalus occurs when a continuous flow of air accumulates in the intracranial cavity and produces a mass effect on the brain. We describe a case in which tension pneumocephalus was caused by the performance of continuous lumbar CSF drainage in a middle-aged man who had experienced a temporal bone fracture. Continuous lumbar CSF drainage is commonly performed in patients with temporal bone or basilar skull fractures to treat concomitant post-traumatic CSF rhinorrhea, CSF otorrhea, and/or hydrocephalus. However; to the best of our knowledge, there has been no previously reported case of tension pneumocephalus occurring as a complication of this procedure in a patient with a temporal bone fracture.

Complete ophthalmoplegia associated with clival fracture following trauma: Case report and clinicoanatomical correlation

Fractures of clivus occur following high energy trauma and are rare. There are a few reports of associated vascular and brainstem injury in literature. We report a patient with transverse clivus fracture and complete ophthalmoplegia and bilateral multiple cranial nerve palsies. A young boy was admitted in altered sensorium following RTA. Initial imaging revealed diffuse pneumocephalus, subarachnoid hemorrhage and diffuse cerebral edema. He was treated conservatively. Clinical review after improvement in sensorium showed that he had visual loss in left eye, bilateral ptosis, complete ophthalmoplegia in horizontal as well as vertical gaze, bilateral trigeminal paresis, right facial weakness and dysarthria. There was right CSF otorrhea. A spiral CT scan revealed transverse clivus fracture extending into bilateral middle cranial base. The fracture line was involving facial canal and mastoid on the right side. An MRI brain demonstrated periaqueductal infarcts and multiple cortical infarcts. He was managed conservatively. In the presence of clinical suspicion of skull base injuries, a spiral CT scan and MRI brain and MR angiography are essential for accurate assessment of bony and neurological involvement. The diagnosis of clivus fracture should prompt the clinician to look for associated brainstem or basilar artery injury.

Spontaneous CSF Otorrhea From a Defect in the Medial Wall of the Middle Ear

Spontaneous CSF Otorrhea From a Defect in the Medial Wall of the Middle Ear

Spontaneous CSF Otorrhea: Case Series and Correlation with Radiologic Empty Sella

Spontaneous CSF Otorrhea: Case Series and Correlation with Radiologic Empty Sella

Small postaural incision for paediatric cochlear implantation

Objective Cochlear implantation is now a well-accepted procedure in the paediatric population. The objective of this study was to evaluate the use of small postaural incision for cochlear implantation in children.Methods This study is a retrospective review of patients who had cochlear implantation using small postaural incision. Patient records of 34 patients who were implanted using this incision are reviewed. The technique involves drilling the bony well for the implant inside a small subperiosteal pocket standing opposite the operated ear. The rest of the steps were the same as for standard cochlear implantation.Results The technique proved to be very successful in all the cases. Three patients (3/34) had complications, of which two (CSF gusher and otorrhoea) were unrelated to the incision and one patient developed a mild keloid in the incision. None of the patients developed haematomas or wound infection. The incision healed well in all the cases. The average operating time was 2.5 h (which includes trainees operating and difficult cases) which dropped to 2 h when the entire operation was done by the senior surgeon. In none of the cases did the incision have to be extended for exposure. The average postoperative follow up was 18 months. Patient and parent satisfaction with the small incision was extremely high.Conclusions Cochlear implantation using small postaural incision approach has shown good results in this series. It has been well accepted by children, their parents and the other members of the cochlear implant team. It reduces morbidity associated with a big incision and helps in quicker recovery from the operation.

Small postaural incision for paediatric cochlear implantation

Cochlear implantation is now a well-accepted procedure in the paediatric population. The objective of this study was to evaluate the use of small postaural incision for cochlear implantation in children.This study is a retrospective review of patients who had cochlear implantation using small postaural incision. Patient records of 34 patients who were implanted using this incision are reviewed. The technique involves drilling the bony well for the implant inside a small subperiosteal pocket standing opposite the operated ear. The rest of the steps were the same as for standard cochlear implantation.The technique proved to be very successful in all the cases. Three patients (3/34) had complications, of which two (CSF gusher and otorrhoea) were unrelated to the incision and one patient developed a mild keloid in the incision. None of the patients developed haematomas or wound infection. The incision healed well in all the cases. The average operating time was 2.5 h (which includes trainees operating and difficult cases) which dropped to 2h when the entire operation was done by the senior surgeon. In none of the cases did the incision have to be extended for exposure. The average postoperative follow up was 18 months. Patient and parent satisfaction with the small incision was extremely high.Cochlear implantation using small postaural incision approach has shown good results in this series. It has been well accepted by children, their parents and the other members of the cochlear implant team. It reduces morbidity associated with a big incision and helps in quicker recovery from the operation.