New Considerations in the Cause of Spontaneous Cerebrospinal Fluid Otorrhea

Goddard, John C.; Meyer, Ted A.; Nguyen, Shaun A.; Lambert, Paul R.

doi:10.1097/mao.0b013e3181e8f36c

Cited by 85 publications

(100 citation statements)

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“…8,22,24,26,27 We found that the mean BMI and the prevalence of empty sella syndrome were higher in patients with spontaneous lesions than in those with nonspontaneous lesions; however, these differences did not reach statistical significance. Our data reveal a female preponderance among patients with spontaneous CSFFs, similar to that observed among patients with idiopathic intracranial hypertension syndrome.…”

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confidence: 43%

“…It has been hypothesized that elevated intracranial pressure may contribute to progression of temporal bone encephaloceles and CSFF, and an increased risk of recurrence following repair. 1,8,22,26 Given the rarity of the studied conditions, few large series exist in the literature, and optimal surgical management remains controversial. 7,14,15,20,21 Treatment options include the transmastoid approach with tegmen repair or tympanomastoid obliteration, subtemporal middle fossa craniotomy, or a combined mastoid-middle fossa approach.…”

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confidence: 99%

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

Carlson¹,

Copeland

Driscoll

et al. 2013

JNS

116

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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/m2, 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.

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mentioning

confidence: 43%

mentioning

confidence: 99%

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

Carlson¹,

Copeland

Driscoll

et al. 2013

JNS

116

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“…1 Recently there has been growing evidence that obesity is also a risk factor for development of spontaneous temporal bone CSF leaks. 6,12,17,21 In contrast, little has been written regarding the possible association between obesity and the occurrence of a CSF leak following VS surgery. 8,14 Diaz Anadon et al studied 170 patients who had undergone surgery for tumors in the cerebellopontine angle (163 of whom had a VS) and found no relationship between CSF leaks and BMI.…”

Section: Discussion Elevated Bmi As a Risk Factor For A Csf Leakmentioning

confidence: 99%

Are there modifiable risk factors to prevent a cerebrospinal fluid leak following vestibular schwannoma surgery?

Copeland¹,

Mallory²,

Neff

et al. 2015

JNS

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OBJectThe following study was conducted to identify risk factors for a postoperative CSF leak after vestibular schwannoma (VS) surgery. MethODs The authors reviewed a prospectively maintained database of all patients who had undergone resection of a VS at the Mayo Clinic between September 1999 and May 2013. Patients who developed a postoperative CSF leak within 30 days of surgery were compared with those who did not. Data collected included patient age, sex, body mass index (BMI), tumor size, tumor side, history of prior tumor treatment, operative time, surgical approach, and extent of resection. Both univariate and multivariate regression analyses were performed to evaluate all variables as risk factors of a postoperative CSF leak. results A total of 457 patients were included in the study, with 45 patients (9.8%) developing a postoperative CSF leak. A significant association existed between increasing BMI and a CSF leak, with those classified as overweight (BMI 25-29.9), obese (BMI 30-39.9), or morbidly obese (BMI ≥ 40) having a 2.5-, 3-, and 6-fold increased risk, respectively. Patients undergoing a translabyrinthine (TL) approach experienced a higher rate of CSF leaks (OR 2.5, 95% CI 1.3-4.6; p = 0.005), as did those who had longer operative times (OR 1.04, 95% CI 1.02-1.07; p = 0.0006). The BMI, a TL approach, and operative time remained independent risk factors on multivariate modeling. cONclusiONs Elevated BMI is a risk factor for the development of a postoperative CSF leak following VS surgery. Recognizing this preoperatively can allow surgeons to better counsel patients regarding the risks of surgery as well as perhaps to alter perioperative management in an attempt to decrease the likelihood of a leak. Patients undergoing a TL approach or having longer operative times are also at increased risk of developing a postoperative CSF leak.http://thejns.org/doi/abs/10.3171/2014.10.JNS14432 Key WOrDs cerebrospinal fluid leak; vestibular schwannoma; acoustic neuroma; predictors; risk factors; oncology aBBreviatiONs BMI = body mass index; ICP = intracranial pressure; MF = middle fossa; RS = retrosigmoid; TL = translabyrinthine; VS = vestibular schwannoma.

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“…14 The purpose of the present study is to add our series to the limited number of previously published cases, to compare the PF variety of transtemporal CSF leakage with the more common MF route in terms of demographics, clinical presentation, imaging characteristics, and potential etiologies.…”

Section: Introductionmentioning

confidence: 99%

“…The MF is more prone to dehiscence and CSF leak due to a combination of a thinner bony plate and a higher proportion of AGs compared with the posterior petrous face. [11][12][13] Recently in the last 5 to 10 years, associations between temporal bone CSF leak, obesity, [6][7][8]14,15 and idiopathic intracranial hypertension (IIH) 3,5,6,[14][15][16] have been noted. IIH interestingly shares the similar demographics of age 40 to 60, female gender, and BMI greater than 30.…”

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confidence: 99%

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

2011

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Spontaneous temporal bone cerebrospinal fluid (CSF) leak is defined as a communication between the subarachnoid space and the pneumatized space of the temporal bone, and is distinguishable from leaks caused by trauma, neoplasm, or infection. [1][2][3][4] This rare phenomenon is often due to a defect in the tegmen of the middle ear or mastoid, and rarely in the posterior fossa (PF) plate of the petrous bone. A disproportionate number of patients with middle fossa (MF) leaks are female, aged 40 to 60 with a body mass index (BMI) greater than 30. 3-8 Patients typically present with conductive hearing loss, aural fullness, and cerebrospinal otorrhea. 1,6,9,10 Due to the rarity of PF leaks, the demographics and clinical presentation are less well defined.The etiology of the defects in the dura and underlying temporal bone is subject to considerable debate in the literature. The arachnoid granulation (AG) theory has become widely cited as causative for both MF and PF leaks. The proponents of this theory describe aberrant AGs sitting against bone causing slow erosion over time. The MF is more prone to dehiscence and CSF leak due to a combination of a thinner bony plate and a higher proportion of AGs compared with the posterior petrous face. [11][12][13] Recently in the last 5 to 10 years, associations between temporal bone CSF leak, obesity, 6-8,14,15 and idiopathic intracranial hypertension (IIH) 3,5,6,14-16 have been noted. IIH interestingly shares the similar demographics of age 40 to 60, female gender, and BMI greater than 30. Some authors have incorporated these findings into the AG theory, designating the AG's as an arrowhead leading a process of erosion due to unexplained increased intracranial pressure. 6,10,13 Others simply identify Keywords ► cerebrospinal fluid leak ► arachnoid granulation ► petrous bone ► posterior fossa AbstractSpontaneous cerebrospinal fluid (CSF) leak through the posterior fossa (PF) aspect of the petrous bone is exceedingly rare. A case series allows analysis of etiologies and how they may differ from the more common middle fossa (MF) route of leakage. The design was a retrospective case series. The setting was a tertiary care institution. A series of three patients with PF spontaneous CSF leaks was identified. High-resolution imaging (CT and MRI) and intraoperative observations were evaluated. Both in this series and in previously reported cases, patients share the demographics typically found in the MF leak population. In our series, two patterns of PF CSF leak were identified: (1) large unilateral with cerebellar encephalocele and (2) small punctate defects just lateral to the endolymphatic sac. Two presented with simultaneous MF and PF leaks suggesting a shared etiology, at least in some cases, with a role for increased intracranial pressure. 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 th...

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New Considerations in the Cause of Spontaneous Cerebrospinal Fluid Otorrhea

Cited by 85 publications

References 28 publications

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

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

Are there modifiable risk factors to prevent a cerebrospinal fluid leak following vestibular schwannoma surgery?

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

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