Impact of Obesity and Obstructive Sleep Apnea in Lateral Skull Base Cerebrospinal Fluid Leak Repair

Abstract

ObjectiveTo investigate the prevalence and impact of obstructive sleep apnea (OSA) and obesity in lateral skull base cerebrospinal fluid leak repair (LSBR) of various etiologies.MethodsRetrospective case review at a tertiary skull base center was conducted of consecutive adults undergoing LSBR via transmastoid, middle cranial fossa, or combined approach between 2013–2018. The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma or chronic ear disease were excluded.ResultsNinety‐four patients (67.4% female, mean age 53.5 ± 12.9 years) underwent repair forspontaneous (sCSFL, 44%) and other etiology (nsCSFL) leaks. nsCSFL served as a comparisongroup consisting of leaks status‐post lateral skull base surgery, temporal bone fractures, andchronic ear disease. Class III obesity (P = .02), OSA (P = .03), and imaging findings of empty sella (OR = 3.32, P = .02), and skull base thinning including contralateral tegmen thinning (31%, OR = 4.3, P = .02), arachnoid granulations (26%, OR = 4.35, P = .02), and superior canal dehiscence (15.8%, OR = 8.57, P = .04) were more common in sCSFL. Four patients (4.2%) required surgical revision for recurrence, and another four (4.2%) resolved with shunting. Evidence of elevated intracranial hypertension was present in nine patients with sCSF leaks and was predictive of need for revision or shunt procedures (P < .01).ConclusionObesity, OSA, and imaging consistent with elevated intracranial pressures were more common among patients with sCSFL. Elevated intracranial pressure predicted outcomes following multilayer repair of spontaneous CSF leaksLevel of Evidence4 Laryngoscope, 130:2234–2240, 2020

Spontaneous temporal cerebrospinal fluid leak

“…[1][2][3][4]17,19 A recent data survey shows that the average age of patients diagnosed with spontaneous temporal CSF leaks is 56.9 years, ranging from 45.7 to 63 years. 3,6,[8][9][10]17,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] The patient's age in this report is, in a way, consistent with the hypothesis that spontaneous temporal CSF leak is associated with years of pulsation of intracranial content in regions of thin bones due to increased pneumatization, dehiscence or arachnoid granulations presence of the middle fossa floor. Regarding gender, most studies have noted a higher proportion of women to men in the development of spontaneous temporal CSF leaks, while others have not observed this trend.…”

“…Studies point to an average of 10.2% of bilateral cases. 6,8,10,17,[20][21][22][23]28 In addition, spontaneous CSF leaks may be predisposed by clinical conditions, such as obesity, obstructive sleep apnea syndrome and idiopathic intracranial hypertension. These conditions are associated with a chronic increase in intracranial pressure, contributing to the development of bone erosions by increasing the the intracranial content pulsation pressure against the skull base with its consequent erosion.…”

“…A recent survey has showed that 64% of the spontaneous CSF leaks are associated with herniations. 3,[8][9][10]17,18,20,[22][23][24]26,29,30,32,37 In addition, the pathophysiology of spontaneous CSF leaks, due to anatomical issues, is associated to superior semicircular canal dehiscence. In patients with spontaneous temporal CSF leaks, approximately 13.1% will be associated to superior semicircular canal dehiscence.…”

“…[1][2][3] They may be due to the failed development of the temporal bone or the presence of aberrant arachnoid granulations 1,3,4 and are favored by idiopathic intracranial hypertension, obstructive sleep apnea and obesity. [5][6][7][8][9][10] Temporal CSF leaks may also be associated with the presence of herniations of the intracranial content (meningoceles and meningoencephaloceles) and with dehiscence of the superior semicircular canal. [11][12][13] The clinical presentation is usually insidious and nonspecific, which tends to delay the diagnosis.…”

Calvarium Thinning in Patients with Spontaneous Cerebrospinal Fluid Leaks of the Anterior Skull Base

“…Transient or chronic increases in ICP are thought to play a significant role in the development of sCSF‐Ls by exerting mechanical pressure‐like forces on the skull base and calvarium, which cause thinning of the bone and exposure and tearing of the dural layers. Furthermore, elevated ICPs and thinner skull bases have been associated with higher rates of postsurgical complications 19,20 …”