Temporal Bone Cerebrospinal Fluid Leaks Research Articles

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.

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

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. Retrospective chart review. Tertiary care hospital. Fifty-two adult patients undergoing transmastoid (TM), middle fossa (MF) or combined approach repair of spontaneous MF CSF leak between 2016 and 2020. 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). Successful repair without recurrent CSF leak or encephalocele throughout follow-up. Cost of materials used in duraplasty. 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/m 2 . 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. 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.

Comparison of Outcomes of Surgical Repair of Spontaneous Temporal Bone CSF Leaks and Encephaloceles Using Bone Cement and Autologous Material.

To compare outcomes transmastoid repair of spontaneous middle fossa cerebrospinal fluid (CSF) leak using only bone cement (BC) versus only autologous material (AM) or combined materials (CM) with both bone cement and autologous material. Retrospective Chart Review. Tertiary Care Hospital. Forty-three adult patients undergoing transmastoid repair of spontaneous middle fossa CSF leak between 2014 and 2020 (BC:12, AM:15, CR:16). Cortical mastoidectomy, identification of defect, and repair with BC (Cranios® hydroxyapatite), AM (local bone, fascia, fat, and/or cartilage), or CM (Cranios® combined with autologous materials). Successful repair without recurrent CSF leak or encephalocele throughout follow up. Fifty-one percent of subjects were female. Mean age at repair was 58.6 years (SD 10.9). Mean BMI was 35.4 (SD 7.6; BC:36.3, AM:36.5, CM:33.6). Forty (93%) patients had successful repair without known recurrent CSF leak or encephalocele since surgery (BC:11, 91.6%; AM:14, 93.3%; CM:15, 93.8%; p = 0.49) over a mean length of follow up of 49.6 months (BC: 37.9, AM: 59.2, CR: 49.5). The difference in mean operative time amongst the groups was faster for patients using bone cement (BC: 100.2 min, AM: 182.8, CM: 133.2; p < 0.00001). BC, AM, and CM techniques each demonstrate effective and sustained means of repair for middle fossa CSF leak and encephalocele, even in the presence of multiple defects. Use of isolated BC offers a significant decrease in operative time with a noninferior outcome. Active CSF leak at the time of surgery is associated with increased risk of recurrence.

Comparison of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks From the Middle and Posterior Fossa.

To compare patients surgically managed for spontaneous cerebrospinal fluid (CSF) leaks of the temporal bone arising from the middle cranial fossa (MCF) and posterior cranial fossa (PCF) and to describe the surgical management of posterior fossa CSF leaks. Retrospective case review. Academic tertiary center. Adult patients presenting with spontaneous temporal bone CSF leaks undergoing operative repair between January 2010 and August 2018. Patients with a history of trauma, previous mastoid surgery, and iatrogenic CSF leaks were excluded. Transmastoid or MCF CSF leak repair. Patient demographics, body mass index (BMI), comorbidities, presenting features, and lumbar puncture opening pressures were compared between groups and the management of the PCF CSF leaks described. Forty-six patients (26 women, 20 men) were included. The mean age at the time of repair was 58.0 ± 12.9 years (±SD). The origin of the CSF leak was from the PCF in three patients and MCF in 43 patients. All three patients with PCF leaks presented with an acute history of meningitis compared with only seven (16%) in the MCF group. This difference was statistically significant (p = 0.01, Fisher's exact test). There were no statistically significant differences in age, sex, BMI, or lumbar puncture opening pressures. The PCF leaks were repaired using a transmastoid approach with multilayer closure of the bony defect and fat graft obliteration of the mastoid. Spontaneous CSF leaks arising from the PCF are rare and may present more commonly with meningitis. Identification requires careful review of imaging.

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

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. Retrospective imaging review. Academic medical center. Patients with cerebrospinal fluid leaks or other middle ear effusions who also underwent MRI. 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. 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. 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

PurposeThe 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). MethodsThis 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. ResultsThe 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. ConclusionThere 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.

Transmastoid Repair of Spontaneous Cerebrospinal Fluid Leaks.

Objective Determine the efficacy of using a purely transmastoid approach for the repair of spontaneous cerebrospinal fluid (CSF) leaks and further elucidate the relationship of elevated body mass index (BMI) and skull base thickness in our patient population. Method We conducted a retrospective chart review of patients treated for spontaneous temporal bone CSF leaks at our tertiary care institution from the years 2006 to 2015. Cases were categorized as primary or secondary. We analyzed success rates, length of stay, use of lumbar drains, BMIs, and rates of meningitis. Skull base thickness was compared with BMI in each case. Results We identified 26 primary operations for spontaneous CSF leaks and 7 secondary operations. Twenty-three of 33 repairs were performed via the transmastoid approach alone with an 87% success rate (20/23). Of the10 repairs including a middle cranial fossa (MCF) or combined MCF-transmastoid approach, 2 failed for an 80% success rate (8/10). Five transmastoid repairs underwent placement of a lumbar drain versus all 10 repairs employing an intracranial exposure. Average length of stay for those undergoing a transmastoid approach (1.7 days) was significantly shorter than for patients undergoing a MCF repair (6.3 days). Four patients presented with meningitis. Average BMI was 35.3. No correlation was established between BMI and skull base thickness ( R2 = 0.00011). Conclusion The transmastoid approach is effective in the majority of cases and prevents the need for an intracranial operation, resulting in lower morbidity and a shorter length of stay. We believe that this is the preferred primary approach in most patients with spontaneous CSF leaks.

Massive Cerebrospinal Fluid Leak of the Temporal Bone

Cerebrospinal fluid (CSF) leakage of the temporal bone region is defined as abnormal communications between the subarachnoidal space and the air-containing spaces of the temporal bone. CSF leak remains one of the most frequent complications after VS surgery. Radiotherapy is considered a predisposing factor for development of temporal bone CSF leak because it may impair dural repair mechanisms, thus causing inadequate dural sealing. The authors describe the case of a 47-year-old man with a massive effusion of CSF which extended from the posterior and lateral skull base to the first cervical vertebrae; this complication appeared after a partial enucleation of a vestibular schwannoma (VS) with subsequent radiation treatment and second operation with total VS resection.

Transmastoid Approach to Spontaneous Temporal Bone Cerebrospinal Fluid Leaks: Hearing Improvement and Success of Repair

To determine whether the transmastoid approach to repair of spontaneous temporal bone cerebrospinal fluid (CSF) leak is safe and effective and if improvement in conductive hearing loss is an achievable goal with this approach. Case series with chart review. Tertiary academic medical center. Fifteen consecutive patients (16 ears) presented with spontaneous temporal bone CSF leaks over a 6-year period. Clinical data, imaging, audiometry, operative reports, and postoperative course were reviewed. Median age was 59.5 years. Mean body mass index was 40.7 kg/m2. All presented with chronic otorrhea after tympanostomy tube placement and conductive/mixed hearing loss. The mean preoperative air-bone gap was 19 dB. A transmastoid approach alone was used in 15 cases; 1 underwent middle fossa craniotomy. Most defects were located in the tegmen mastoideum and tympani. All repairs were multilayered, typically using autologous mastoid bone, temporalis fascia, and tissue sealant. Primary repair was successful in 15 cases; 1 patient with persistent postoperative otorrhea subsequently underwent middle fossa craniotomy, but no frank leakage was found. No serious complications were encountered. Following transmastoid repair, postoperative audiograms were available for 14 patients. The mean improvement in air-bone gap was 12 dB. Closure of the air-bone gap to ≤12 dB occurred in 100% of cases. The transmastoid approach to repair of spontaneous temporal bone CSF leak is highly successful. Furthermore, patients in this series had excellent hearing results with closure of their air-bone gap to ≤12 dB, which has not been previously described.

Otogenic pneumocephalus secondary to recurrent cholesteatoma and associated temporal bone cerebrospinal fluid leak

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Spontaneous Cerebrospinal Fluid Leak through the Posterior Aspect of the Petrous Bone

Objective: Spontaneous cerebrospinal fluid (CSF) leak through the posterior fossa aspect of the petrous bone (PF) is very rare. A case series allows analysis of possible etiologies and how they may differ from the more common middle fossa (MF) route of leakage. Method: A series of 3 patients with PF spontaneous temporal bone CSF leaks is described. High-resolution imaging (CT &amp; MRI) and intraoperative observation characterize the anatomical characteristics of the pathway. Results: This series of patients did share the demographics typically found in the MF leak population. Two patterns of PF CSF leak were identified: large unilateral with cerebellar encephalocele and bilateral small defects just lateral to the endolymphatic sac. Two out of our 3 patients presented with simultaneous MF and PF leaks suggesting the possibility of a shared etiology, at least in some cases, with a role for increased intracranial pressure. Conclusion: In spontaneous CSF leaks it is important to evaluate the posterior petrous bone along with the tegmen. The concomitant appearance of MF with PF leaks points out the risk that repair via MF craniotomy could fail to identify a leakage site in the vicinity of the endolymphatic sac.

Cerebrospinal Fluid Leaks of Temporal Bone Origin: Selection of Surgical Approach

Cerebrospinal fluid leaks of the temporal bone are rare, often occult, and sometimes challenging to localize and repair. This is a retrospective study of eight patients with spontaneous cerebrospinal fluid leak and six patients with cerebrospinal fluid leak or encephalocele discovered during chronic ear surgery who were treated in a tertiary medical center over a 5-year period. All received preoperative temporal bone computed tomography, and six also underwent magnetic resonance imaging, one computed tomography cisternography, and one radionuclide cisternography. All patients initially underwent a transmastoid surgical approach. Additional exposure was necessary in three patients; two underwent middle fossa craniotomy and another required minicraniotomy. Primary surgical repair was successful in six of the eight patients with spontaneous leaks and in all six chronic ear patients. Both recurrences required intradural middle fossa repair. An individualized approach should be taken for repair of temporal bone cerebrospinal fluid leaks. In this series, most were successfully repaired in a single stage using a transmastoid or combined approach. The transmastoid approach provides information about the precise size and location of the dural defect. A primary transcranial approach is needed for defects that are multiple, located in the petrous apex, and in revision cases.

Evaluation and Management of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks

Spontaneous temporal bone cerebrospinal fluid leak may be defined as a leak without an apparent precipitating cause. These transdural fistulas occur rarely, and diagnosis is predicated upon a high index of suspicion. Leaks have been reported through both middle and posterior fossa defects, although the vast majority involve the middle fossa plate. In a previous study we reported 7 cases of spontaneous temporal bone cerebrospinal fluid leaks, all involving the middle fossa tegmen. Upon further review of these cases and 5 previously unreported cases, the defect was localized to the tegmen tympani in 9 of the total 12 cases. Diagnostic methods are discussed, with the importance of high-resolution computed tomography stressed. The role of contrast cisternography is also evaluated. An outline for surgical management is presented based upon residual hearing and defect location and accessibility. A transmastoid procedure offers the advantage of visualization of both the middle and posterior fossa plates, and this approach can be supplemented with an obliterative procedure when indicated. The middle fossa approach provides optimal exposure of the tegmen plate with less likelihood of ossicular injury when dealing with tegmen tympani defects. Adjuncts to surgical therapy include intrathecal fluorescein dye and continuous postoperative lumbar cerebrospinal fluid drainage.