Temporal bone encephalocele and cerebrospinal fluid fistula repair utilizing the middle cranial fossa or combined mastoid-middle cranial fossa approach.

Departments of Otolaryngology-Head and Neck Surgery and.
Journal of Neurosurgery (Impact Factor: 3.15). 07/2013; DOI: 10.3171/2013.6.JNS13322
Source: PubMed

ABSTRACT Object The goals of this study were to report the clinical presentation, radiographic findings, operative strategy, and outcomes among patients with temporal bone encephaloceles and cerebrospinal fluid fistulas (CSFFs) and to identify clinical variables associated with surgical outcome. Methods A retrospective case series including all patients who underwent a middle fossa craniotomy or combined mastoid-middle cranial fossa repair of encephalocele and/or CSFF between 2000 and 2012 was accrued from 2 tertiary academic referral centers. Results Eighty-nine consecutive surgeries (86 patients, 59.3% women) were included. The mean age at time of surgery was 52.3 years, and the left side was affected in 53.9% of cases. The mean delay between symptom onset and diagnosis was 35.4 months, and the most common presenting symptoms were hearing loss (92.1%) and persistent ipsilateral otorrhea (73.0%). Few reported a history of intracranial infection (6.7%) or seizures (2.2%). Thirteen (14.6%) of 89 cases had a history of major head trauma, 23 (25.8%) were associated with chronic ear disease without prior operation, 17 (19.1%) occurred following tympanomastoidectomy, and 1 (1.1%) developed in a patient with a cerebral aqueduct cyst resulting in obstructive hydrocephalus. The remaining 35 cases (39.3%) were considered spontaneous. Among all patients, the mean body mass index (BMI) was 35.3 kg/m(2), and 46.4% exhibited empty sella syndrome. Patients with spontaneous lesions were statistically significantly older (p = 0.007) and were more commonly female (p = 0.048) compared with those with nonspontaneous pathology. Additionally, those with spontaneous lesions had a greater BMI than those with nonspontaneous disease (p = 0.102), although this difference did not achieve statistical significance. Thirty-two surgeries (36.0%) involved a middle fossa craniotomy alone, whereas 57 (64.0%) involved a combined mastoid-middle fossa repair. There were 7 recurrences (7.9%); 2 patients with recurrence developed meningitis. The use of artificial titanium mesh was statistically associated with the development of recurrent CSFF (p = 0.004), postoperative wound infection (p = 0.039), and meningitis (p = 0.014). Also notable, 6 of the 7 cases with recurrence had evidence of intracranial hypertension. When the 11 cases that involved using titanium mesh were excluded, 96.2% of patients whose lesions were reconstructed with an autologous multilayer repair had neither recurrent CSFF nor meningitis at the last follow-up. Conclusions Patients with temporal bone encephalocele and CSFF commonly present with persistent otorrhea and conductive hearing loss mimicking chronic middle ear disease, which likely contributes to a delay in diagnosis. There is a high prevalence of obesity among this patient population, which may play a role in the pathogenesis of primary and recurrent disease. A middle fossa craniotomy or a combined mastoid-middle fossa approach incorporating a multilayer autologous tissue technique is a safe and reliable method of repair that may be particularly useful for large or multifocal defects. Defect reconstruction using artificial titanium mesh should generally be avoided given increased risks of recurrence and postoperative meningitis.

1 Bookmark
  • [Show abstract] [Hide abstract]
    ABSTRACT: In the well pneumatized temporal bone, the temporal lobe of the brain is separated from the middle ear and mastoid process by a thin layer of bone known as the tegmen. Congenital defects, infection, and trauma can alter this structure in such a way that cerebral tissue herniates into the ear. This unusual condition may precipitate numerous otologic problems such as hearing loss, trapped squamous epithelium, and the potential for meningitis or encephalitis.The purpose of this paper is to define the problem as well as discuss the diagnosis and surgical management. The authors feel this should be a team effort, in many cases employing the assistance of a neurosurgeon, as the repair must often be intradural. Case histories and an extensive review of the literature are to be included.
    The Laryngoscope 01/2009; 89(11):1743 - 1754. · 1.98 Impact Factor
  • Otolaryngology Head and Neck Surgery 05/1985; 93(2):146-7. · 1.73 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Alternative methods of multilayer reconstruction for cranial basal defects are discussed in this report. The reconstruction procedure employs usage of multiple layers of vascularised pedicle flaps which are placed over one another. The extensive vascular supply to the temporalis muscle and its fascial coverings was exploited in fashioning the flaps. The procedure not only provided a compact sealing of the defect, but by virtue of its volume helped in reducing the dead space. The technical issues concerning the harvesting of the flaps and their indications are discussed in this report.
    Acta Neurochirurgica 02/1996; 138(5):584-9. · 1.55 Impact Factor