Spontaneous Cerebrospinal Fluid Otorrhea Research Articles

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.

Audiometric outcomes following surgery for spontaneous temporal bone cerebrospinal fluid leaks – A single institution study

PurposeTo assess the audiometric outcomes following surgical repair of spontaneous temporal bone cerebrospinal fluid otorrhea and compare different surgical approaches. Materials and methodsRetrospective review of adults (≥18 years old) who underwent repair of spontaneous CSF leak between 2011 and 2022. Audiometric outcomes were compared across the three surgical groups: transmastoid, middle cranial fossa and combined. ResultsThirty-nine patients (40 ears) met the inclusion criteria (71.8 % females; mean age 59.77 +/− 12.4). Forty-two percent underwent transmastoid, 12.5 % middle cranial fossa and 45 % transmastoid-middle cranial fossa. Four patients (10 %) had recurrence, 3 in the transmastoid group and 1 in the combined approach. The mean change in air-bone gap (ABG) for all patients (postoperative-preoperative) was −7.4 (paired t-test, p-value = 0.0003). The postoperative ABG was closed in 28 (70 %) ears (postoperative ABG ≤ 15). The mean change in pure tone average (PTA) for all patients (postoperative-preoperative) was −4.1 (paired t-test, p-value = 0.13). The mean change in word recognition scores (WRS) for all patients (postoperative-preoperative) was −3 (paired t-test, p-value = 0.35). On multivariable analysis (controlling for site and reconstruction material), there was no significant difference in ABG, PTA and WRS change between surgical groups. ConclusionsTransmastoid, middle cranial fossa and combined approaches are all effective in treatment of spontaneous CSF leaks and all showed mean decrease in post-operative ABG. Transmastoid approach showed the greatest decrease in ABG and PTA (although middle cranial fossa approach shows the greatest decrease, when excluding profound hearing loss in a patient with superior canal dehiscence). Further studies comparing audiometric outcomes are needed.

Analysis of 3 Surgical Approaches for the Treatment of Cerebrospinal Fluid Otorrhea: A Case Series Report.

Background: This case series report aimed to present three surgical approaches used for the treatment of cerebrospinal fluid (CSF) otorrhea, providing less invasive surgical options for managing this condition. Methods: Clinical data of 26 patients with CSF otorrhea, who underwent treatment using three surgical methods between June 2012 and June 2022, were retrospectively analyzed. The study collected information on patients' basic demographic characteristics, chief complaints, location of the defect, results of otorrhea endoscopic examination, findings from skull base thin-slice computed tomography (CT) examination, and causes of CSF otorrhea. Postoperative outcomes of CSF otorrhea were followed up. Results: Among the 26 cases of CSF otorrhea, there were 13 (50%) males and 13 (50%) females who underwent treatment using the three surgical methods. The etiology of CSF otorrhea included 10 (38%) cases of spontaneous CSF otorrhea, including 2 (8%) cases of congenital inner ear deformity and 8 (31%) cases without obvious inducement. Additionally, there were 5 (19%) cases of trauma, 6 (23%) cases of cholesteatoma complications, 3 (12%) cases of postoperative complications of brain tumor, 1 (4%) case of radiotherapy, and 1 (4%) case of a malignant tumor. A total of 12 (46%) cases of CSF otorrhea were treated by local repair of the defect. Furthermore, 3 (12%) cases underwent local repair of the defect combined with sealing of the tympanic sinus entrance, while 11 (42%) cases underwent local repair of the defect combined with sealing of the eustachian tube and the external auditory canal. No recurrence of CSF otorrhea was observed during the 6-month to 10-year follow-up period after surgery. Conclusion: The three methods for CSF otorrhea, including local defect repair, local defect repair combined with sealing of the tympanic sinus entrance, and sealing of the eustachian tube and the external auditory canal, demonstrated successful outcomes in appropriately selected patients.

Spontaneous Cerebrospinal Fluid Rhinorrhea and Otorrhea: A Case Report and Literature Review.

Spontaneous cerebrospinal fluid (CSF) leak is a condition that commonly presents with unilateral watery drainage from the nose or ear, tinnitus, and stuffy ears or hearing loss. Spontaneous CSF rhinorrhea and otorrhea together are rare. A 64-year-old woman presented at our department with complaints of clear watery rhinorrhea and hearing loss on the right side persisting for 10months. Imaging and surgery were used to diagnose the condition. Through surgical treatment, she was eventually cured. Review of the literature has shown that patients with both nasal and aural CSF leaks are rare. When a patient presents with both unilateral watery drainage from both the nose and ear, a diagnosis of CSF rhinorrhea and otorrhea should be considered. This case report will benefit clinicians by providing more information to assist with diagnosing the disease.

Spontaneous cerebrospinal fluid leaks of the temporal bone – clinical features and management outcomes

Objective:1.To characterise the clinical profile, symptoms and examination findings of patients with spontaneous cerebrospinal fluid otorrhoea.2.To evaluate the management outcomes of patients with spontaneous cerebrospinal fluid otorrhoea. MethodsA retrospective cohort study over seven-years from 2013 to 2020 was conducted at five tertiary referral centres. Patients identified with biochemically confirmed spontaneous cerebrospinal fluid leaks of the temporal bone manifesting as middle ear fluid with no other obvious cause were included. Demographics (age, gender, body-mass-index), symptomatology, past medical history, examination, investigation (biochemical and radiological), management and outcomes were recorded. Results90 adult patients with spontaneous cerebrospinal fluid otorrhoea were identified. Right sided leaks were most common (58%), and a majority of the cohort overweight (mean body-mass-index = 29.2 kg/m2). Unilateral hearing loss was the commonest presenting symptom (81%). Two patients presented to hospital with meningitis presumed secondary to spontaneous cerebrospinal fluid otorrhoea. Over half (54%) of patients were observed who tended to be older (mean age of 71 years vs 62 years) whilst the remainder underwent surgical repair with middle-fossa craniotomy the most common approach (87%). Eight patients managed surgically had recurrent leaks (21%). ConclusionsThis is one of the largest cohorts of spontaneous cerebrospinal fluid otorrhoea reported in the literature and reiterates the importance for clinicians to have a high index of suspicion for this condition in patients presenting with a unilateral middle ear effusion, especially in those who are overweight. Surgical intervention carries a risk of recurrence and further studies are needed to determine the risk of intra-cranial infection in order to guide management.

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.

Minimally Invasive Repair of Tegmen Defects Through Keyhole Middle Fossa Approach to Reduce Hospitalization

The middle fossa craniotomy for tegmen defect repair provides wide access. This approach often requires temporal lobe manipulation, lumbar drain placement, and longer recovery. We describe a keyhole middle fossa approach with a simple titanium skull base repair that allows for wide access with no temporal lobe manipulation and does not require lumbar drain placement, which results in a dramatic reduction in hospital length of stay. A retrospective review was performed on 14 consecutive patients with spontaneous cerebrospinal fluid (CSF) otorrhea. Each patient underwent a keyhole middle fossa approach followed by multilayer dural repair with titanium mesh "gull wing" skull base reconstruction. Postoperative measures included operative time, length of hospital stay, CSF leak recurrence, and surgical complications (seizures, hemorrhage, aphasia, infection). The average age of the patients was 60.7±12.7 years old, and average body mass index was 32.8 ± 7.9 kg/m2. Nine of the patients were female. The average operative time was 103 ± 32.8 minutes. The average hospital length of stay was 1.4 days. There were no cases of postoperative CSF otorrhea, meningitis, aphasia, or seizures. There were no recurrences over a mean follow-up of 20.3 months (range: 5-48 months). A minimally invasive keyhole middle fossa approach with a multilayer dural reconstruction including titanium mesh "gull wing" skull base repair provides a quick, effective treatment for a broad spectrum of tegmen defects and meningoencephaloceles. This exposure and reconstruction technique do not require the use of a lumbar drain and result in minimal hospitalization.

Spontaneous cerebrospinal fluid (CSF) otorrhoea in Western Australia—an emerging entity?

Background: Spontaneous cerebrospinal fluid (CSF) otorrhea appears to be an emerging clinical entity. The aetiology, characteristics and treatment outcomes of these group of patients are poorly described so we aimed to further investigate this growing cohort. Methods: A retrospective review across the three largest tertiary hospitals in Western Australia (WA) over a 5-year period was conducted. Twenty-eight patients with non-iatrogenic, and non-traumatic spontaneous CSF otorrhea were included. Baseline demographics, presenting symptoms, past medical history, clinical examination, investigation (biochemical and radiological), management and outcomes were analysed. The study was approved by the South Metropolitan Health Services Ethics Committee (approval number RG001008). Results: The majority of patients were female (61%), obese (mean BMI =29.5 kg/m 2 ) and presented with a unilateral middle ear effusion and conductive hearing loss. Beta-trace protein sampling of the fluid was positive for CSF in 26 of the 28 patients. The most frequent site of leak was at the tegmen mastoideum and middle cranial fossa repair was the most commonly performed procedure with excellent outcomes. Only one patient had confirmed benign intracranial hypertension and two patients presented emergently to hospital with meningitis thought to be due to the CSF leak. Conclusions: Spontaneous CSF otorrhea should be suspected in unilateral middle ear effusion of unknown cause, especially occurring in at-risk individuals including those whom are obese and of female gender. Clinical or radiological diagnosis alone appears inadequate in diagnosing a spontaneous CSF leak unless clinicians have a high index of suspicion. This emerging entity does not appear to be solely a consequence of raised intracranial pressure and further studies to elucidate the cause are required.

Fallopian Canal Meningocele with Spontaneous Cerebrospinal Fluid Otorrhea: Case Report and Systematic Review of the Literature

To present a case of spontaneous cerebrospinal fluid (CSF) otorrhea from a fallopian canal meningocele involving the geniculate fossa and review all cases of fallopian canal CSF leak reported in the literature with discussion of management and outcomes. A 53-year-old woman with history of morbid obesity and hypertension presented to a tertiary care referral center with unilateral high-volume CSF otorrhea. High-resolution temporal bone computed tomography demonstrated significant dilatation of the geniculate fossa. Rates of postoperative facial paralysis and refractory CSF leak were reported for the present case and prior cases reported in the literature. Locations of fallopian canal dehiscence, surgical approaches, techniques for packing dehiscence, rates of postoperative facial paralysis and CSF leak, and revision procedures were reported for the present case and 14 cases in the literature. The present case involved dehiscence of the geniculate fossa that was approached via combined transmastoid-middle cranial fossa exploration with facial nerve monitoring. The area of dehiscence was carefully packed with temporalis fascia, muscle, and artificial dural substitute overlay to repair the CSF leak without injuring the facial nerve. Postoperatively, no facial weakness was noted; however, right-sided high-volume CSF otorrhea persisted. After discussing treatment options, the patient underwent subtotal petrosectomy and blind-sac closure of the external auditory canal the following day. This successfully resolved the CSF leak without causing facial nerve weakness. Fallopian canal meningocele is an exceedingly rare cause of CSF otorrhea. Successful repair requires precise packing of the dilated facial canal to occlude the leak without injuring the facial nerve. For refractory CSF leak, subtotal petrosectomy and closure of the external auditory canal warrants consideration.

Fallopian Canal Meningocele: A Rare Cause of Cerebrospinal Fluid Otorrhea

Objective Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are extremely rare, with just more than 10 cases reported in the literature. We present a case of spontaneous CSF otorrhea from a fallopian canal meningocele involving the geniculate ganglion.

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.

Middle Ear Obliteration with Blind-Sac Closure of the External Auditory Canal for Spontaneous CSF Otorrhea.

Outcome Objectives To (1) identify unique features of patients who underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal for spontaneous cerebrospinal fluid (CSF) otorrhea and (2) explore outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults treated for spontaneous cerebrospinal fluid otorrhea from 2007 through 2015 were reviewed and stratified into 2 groups based on the surgery performed: (1) 11 patients underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal and (2) 26 patients underwent other procedures. Demographics, body mass index, revised cardiac risk index, Duke Activity Status Index scores, and anticoagulation use were documented. Audiologic data were gathered from pre- and postoperative visits. The primary outcome measure was leak recurrence. Complications were tabulated. Results Poor preoperative hearing was a relative indication for obliteration. Obliteration patients had higher body mass index (43.2 vs 34.9 kg/m2; P < .05), incidence of super-morbid obesity (45% vs 7.6%; P = .015), anticoagulation usage (36% vs 0%; P = .004), cardiac risk scores (1.2 vs 0.1 dB; P < .0004), and Duke Activity Status Index scores. There was 1 leak recurrence (9%). Major and minor complication rates were 9% and 36%, respectively. Mean follow-up was 30.8 ± 8.6 months. Conclusion Middle ear and mastoid obliteration with blind-sac closure of the external auditory canal is effective for treating spontaneous CSF otorrhea. The small cohort reviewed did not experience any major perioperative morbidity. The technique may be best suited for patients with poor hearing, the infirm, and those in whom craniotomy is contraindicated.

The diversity analysis of spontaneous cerebrospinal fluid otorrhea between young children and adults

Objective:To assess the diversity of spontaneous cerebrospinal fluid（CSF）otorrhear in clinical manifestation，CT，leakage sites and surgical operation between young children and adults．Method:We conducted a retrospective study of 6 consecutive patients who were all underwent the surgery through the transmastoid approach，including 4 adults patients and 2 children．In the 4 adults patients，two patients' bony defects lay on the tegmen mastoideum，one lay on the tegmen tympani，and another one lay on the sinus meningioma angle．None of the 4 adults patients had abnormal inner ear structures．Materials used in repair included free muscle graft，temporalis fascia，and fibrin glue of the 4 adults patients．The 2 children patients were diagnosed with congenital abnormalities of the lateral inner ear，who had bony defects of the foot plate or fenestra vestibule．Materials used in repair included free muscle graft，temporalis fascia,and musclein sequence. Result:No CSF leaks recurred after the operation except one adults patient，who's left ear recurred two times and experienced three operations. Conclusion:The clinical manifestations of spontaneous CSF otorrhea between young children and adults are different，the HRCT scan on temporal bone before the operation is very important．Especially foradults patients，making sure of theleakagesites and numbers isvaluable and significance for thesurgical procedure selection．.

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.

In response to Spontaneous middle cranial fossa cerebrospinal fluid otorrhea in adults.

In response to Spontaneous middle cranial fossa cerebrospinal fluid otorrhea in adults.

Association between Lateral Skull Base Thickness and Surgical Outcomes in Spontaneous CSF Otorrhea.

(1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal fluid (CSF) otorrhea. (2) Augment perioperative counseling of patients with abnormally thin skull bases. Case series with chart review. Tertiary center. Patients with spontaneous CSF otorrhea have thin skull bases. This is associated with obesity and/or idiopathic intracranial hypertension. The influence of skull base thinning on perioperative outcomes is unknown. A retrospective review was conducted from 2004 to 2014. Forty-eight cases of spontaneous CSF otorrhea met the inclusion criteria of primary surgery by the senior authors: preoperative dedicated temporal bone computed tomography, absence of other leak etiologies, and follow-up >6 months. Patients were stratified into thin (<0.9 mm) and thick (>0.9 mm) groups based on computed tomography measures of their tegmen. Primary outcomes measures were as follows: postoperative meningitis, recurrent leak, second site leak (contralateral ear/anterior fossa), and permanent shunt placement. Hearing outcomes were not assessed in this study. Thirty and 15 patients composed the thin and thick groups, respectively. Both the incidence (P < .0001) and the rate (P = .005) of adverse outcomes were significantly higher in the thin group. Only 2 patients in the thick group experienced an adverse outcome. Eleven patients underwent multiple procedures for spontaneous leaks. The recurrence rate was 14.5%. All but 1 recurrence occurred in the thin group. An abnormally thin tegmen was significantly associated with adverse perioperative outcomes in cases of spontaneous CSF otorrhea. A thick skull base and the presence of an encephalocele may be protective against recurrence. The effect of untreated intracranial hypertension on the results is unknown.

Obesity related complications in surgery.

This article aims to review relevant implications of obesity and associated comorbid conditions for the otology and neurotology surgical subspecialties. Both the incidence and prevalence of obesity are rising worldwide. This condition, along with its many associated comorbidities, can adversely affect the perioperative management of patients undergoing otologic and neurotologic procedures. Preoperative assessment of the cardiopulmonary system and airway are imperative as compromise of either may lead to death. Physiologic changes found in patients with obesity have been shown to predispose to hemodynamic instability, intolerance of hypoxia, bleeding, thrombo-embolism, poor wound healing, and decreased drug clearance. An 'obesity paradox' may exist in which patients who are overweight or obese may have less perioperative morbidity and mortality. Patients who are underweight or morbidly obese seem to have worse surgical outcomes. Obesity has been associated with intracranial hypertension, risk of cerebrospinal fluid (CSF) leak recurrence, and skull base erosion leading to multiple pathologic conditions. These include spontaneous CSF otorrhea, semicircular canal dehiscence syndrome, and sigmoid sinus diverticulum. The obese habitus and physiology significantly affects patients undergoing otologic and neurologic surgeries. A thorough understanding of this condition is paramount to successful outcomes.

Spontaneous middle cranial fossa cerebrospinal fluid otorrhea in adults.

The goals of this study are to: 1) investigate the urgency for repair of middle cranial fossa spontaneous cerebrospinal fluid (CSF) leaks in adults, and 2) review the literature and treatment recommendations for adult spontaneous CSF otorrhea. 1) All patients who were referred to a tertiary center with spontaneous CSF otorrhea, exposed middle cranial fossa dura, or encephalocele from 2004 to 2015; and 2) landmark references on spontaneous CSF leaks Electronic medical records of patients with a documented spontaneous CSF leak, exposed dura, or encephalocele were reviewed. Subjects were excluded if they had a congenital, traumatic, or iatrogenic CSF leak. Main outcome measure was duration of CSF leak and development of meningitis after clinical presentation. Twenty-two patients (27 ears) who were at risk for meningitis from spontaneous CSF otorrhea, encephalocele, or a dural breach with or without mastoiditis were evaluated. Duration of CSF leaks in patients who refused repair or who continued to have CSF leak after repair or prior to successful repair ranged from 4 months to 11 years. Duration of encephaloceles and dural exposure in an uninfected mastoid ranged from 24 months to 6 years. Only one patient presented with meningitis. None of these 22 patients developed meningitis during the time periods they were under our care. Should patients with CSF otorrhea, exposed dura, or encephalocele refuse operation, it may be reasonable to follow them with close observation and education about warning signs for meningitis.

Novel Radiographic Measurement Algorithm Demonstrating a Link between Obesity and Lateral Skull Base Attenuation

Objectives: (1) Describe a validated measurement instrument to quantify tegmen thickness on computed tomography (CT) images. (2) Compare tegmen thickness in 3 groups: patients with spontaneous cerebrospinal fluid (CSF) leaks, obese controls, and nonobese controls. Methods: Retrospective review from 2005 to present. Patients with a diagnosis of spontaneous CSF otorrhea and dedicated temporal bone CT scans were included. Matched obese (body mass index [BMI] &gt;30) and nonobese (BMI &lt;30) controls were selected from a pool of cochlear implant candidates. The tegmen was measured radiographically in all patients at pre-defined points. Independent, blinded measurements were made by 3 of the authors and compared for interrater validity. Results: Ninety-nine patients were measured: 39 in the CSF group (BMI 35.9), 29 in the obese group (BMI 34.6), and 31 in the nonobese group (BMI 24.2). The CSF group had a significantly thinner aggregate tegmen thickness (0.82 mm ± 0.19) compared with both obese controls (0.99 mm ± 0.18, P = .007) and nonobese controls (1.26 mm ± 0.2, P &lt; .001). Obese controls were thinner than non obese controls ( P &lt; .001). Signs/symptoms of benign intracranial hypertension (BIH) were most commonly found in the CSF group. No other factors significantly affected thickness. Good to excellent correlation of measurements was found between all 3 raters. Conclusions: This is the first study to (1) quantify lateral skull base thickness and (2) significantly correlate obesity with lateral skull base attenuation. Obese spontaneous CSF leak patients may have even greater attenuation of their skull base than matched obese controls. This finding may further support theories that an additional process, such as BIH, may play an important pathophysiologic role in skull base thinning.

ICP, BMI, Surgical Repair, and CSF Diversion in Patients Presenting With Spontaneous CSF Otorrhea

To assess intracranial pressure (ICP), body mass index (BMI), surgical repair, and cerebrospinal fluid (CSF) diversion in patients presenting with spontaneous CSF otorrhea. Retrospective series review. Tertiary referral center. Thirty-two patients were treated surgically from 2004 to 2013 for spontaneous CSF otorrhea by the principal investigators. Patients with a history of chronic ear disease and cholesteatoma, previous mastoid surgery, head trauma, or iatrogenic injury were excluded. Average age was 56 years. Twenty-two patients (69%) were female. Middle fossa repair, transmastoid repair, lumbar puncture, V-P shunt, L-P shunt, and magnetic resonance imaging. Patients underwent middle fossa or transmastoid repair of tegmen defects. Intracranial pressures were determined with lumbar puncture at time of surgical repair or shortly after surgery. CSF diversion procedures were performed in patients who were found to have elevated ICP, which was not controlled medically, presented with recurrent leak or had ICP of 25 cm or greater of H2O. Preoperative BMI was calculated. Thirty-two patients underwent 37 operations. Average BMI was 35.0 kg/m2 (median, 34.7; range, 18.7-53.2 kg/m2). There were 21 repairs on the left and 16 on the right. The majority underwent a middle fossa craniotomy for repair (27/32). Two patients had bilateral repairs. Three patients (8%) underwent revision surgery, of which, 2 had untreated intracranial hypertension (ICP 24.5 and 24 cm H2O). ICP measurements were available for 29 patients. The mean ICP was 23.4 cm H2O (median, 24; range, 13-36 cm H20). Twenty-two patients (69%) had ICP of 20 cm or greater of H20; of those, 13 had an ICP of 25 cm or greater of H20. Seventeen patients (53%) underwent CSF diversion procedures. Our findings of elevated ICP and BMI in patients presenting with spontaneous CSF otorrhea are consistent with previous reports in the literature. The percentage of patients that underwent CSF diversion procedures was high at 53% and represents an aggressive stance in managing elevated ICP in a population that may be at risk for subsequent leaks.