Comparing Outcomes and Billing Costs of Middle Cranial Fossa and Transmastoid Approaches for Otogenic Encephalocele and Cerebrospinal Fluid Leak Repair

Abstract

ObjectiveComparison of outcomes and billing costs of patients treated at our institution using transmastoid (TM), middle cranial fossa (MCF), and combined approaches for repair of otogenic cerebrospinal fluid (CSF) leaks and encephaloceles.Study DesignRetrospective cohort review.SettingTertiary-care hospital.PatientsSeventy-seven cases of otogenic CSF leaks or encephaloceles.InterventionsSurgical repair of an otogenic encephalocele or CSF leak using either a TM, MCF, or combined approach.Main Outcome MeasuresSuccess of repair, length of operation, cost of operating room materials, postoperative need for intensive care, and postoperative length of stay.ResultsForty cases (52%) were performed by the TM approach, 27 (35%) by MCF, and 10 (13%) by combined TM/MCF. Mean length of stay was not statistically different amongst TM patients (2.1 d), MCF patients (3.3 d), and combined TM/MCF patients (3.70; p = 0.112). Only 3/40 TM cases required intensive care during their admission while all MCF and combined TM/MCF approach cases were admitted to the intensive care unit for at least one night (p < 0.001). On follow-up, CSF leak recurred in 3/77 (4%) cases: 3/27 (11%) MCF, 0/40 TM, and 0/10 combined TM/MCF patients (p = 0.056). The mean cost of operating room materials charged to the patient was significantly greater in the MCF group ($9,883) than the TM group ($3,748; p = 0.001).ConclusionsIn carefully selected patients, the TM approach is an effective and less costly alternative to MCF approaches for repair of otogenic CSF leaks and encephaloceles.

Short Postoperative Length of Stay After Lateral Cerebrospinal Fluid Leak Repair

“…Further, rates of CSF leak recurrence and/or need for revision surgery were low and comparable to those previously reported in the literature 15,24,25 . Additionally, the percentage of patients who were admitted to the ICU postoperatively was lower than previously reported in the literature 9 …”

“…15,24,25 Additionally, the percentage of patients who were admitted to the ICU postoperatively was lower than previously reported in the literature. 9 In addition to employing such traditional conservative measures as early mobilization, rigorous pain control and a streamlined multidisciplinary care team approach, the shortened LOS after lateral CSF repair at our institution may in part be attributed to reduced use of LDs. Whereas prior published literature has shown the use of LDs in the treatment of CSF leaks to be common, 26 we have found them rarely to be necessary.…”

“…Three major approaches have been described for the surgical repair of spontaneous lateral CSF leaks: transmastoid (TM), middle cranial fossa (MCF), or combined (TM/MCF). Postoperative care for these patients has historically involved a prolonged inpatient hospitalization of 3 to 5 days, which requires the allocation of substantial resources and time on behalf of both the patient and the health care system 9,10 . Despite being common practice, no specific patient benefits have been demonstrated for longer length of stay (LOS) after lateral CSF leak repair.…”