Diagnosis and Management of Spontaneous Cerebrospinal Fluid‐Middle Ear Effusion and Otorrhea

Brown, Norman D.; Grundfast, Kenneth M.; Jabre, Anthony; Megerian, Cliff A.; O’Malley, Bert W.; Rosenberg, Seth I.

doi:10.1097/00005537-200405000-00002

Cited by 140 publications

(134 citation statements)

References 6 publications

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“…The presence of encephalocele with CSFF, encephalocele without CSFF, and CSFF without encephalocele, as well as the number (1, 2, or multiple), laterality (left, right, or bilateral) and size (< 1 cm, 1-2 cm, or > 2 cm) of bony defects were reported. The preoperative BMI was calculated using the formula BMI = weight (kg)/(height [m]) 2 , and subjects were categorized as underweight (< 18.5 kg/m 18 Preoperative and the most recent postoperative audiometric data, including word recognition scores, bone conduction thresholds, and pure tone averages (0.5, 1, 2, or 3 kHz), were recorded. When the 3-kHz pure tone threshold was not available, the 2-kHz and 4-kHz average was used as a surrogate.…”

Section: Data Collectionmentioning

confidence: 99%

“…Over the last 2 decades, there has been a substantial increase in the number of reported "spontaneous" cases, where no discernable cause can be identified. 2,10,17 Many of these subjects share clinical and radiographic features that overlap with idiopathic intracranial hypertension syndrome. 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.…”

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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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Section: Data Collectionmentioning

confidence: 99%

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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“…The diagnosis of TTD with spontaneous CSF middle ear effusion (MEE) or otorrhoea depends on a high degree of clinical suspicion; however, there is no consensus in the literature on the optimal approach [1] . Nahas et al [4] described 15 cases of TTD, 13 of which involved middle ear CSF effusion.…”

Section: Discussionmentioning

confidence: 99%

“…Dehiscence of the tegmen tympani may be accompanied by herniation of the meninges or brain (meningocele or meningoencephalocele). The findings from an autopsy study suggest that 15% to 34% of specimens contain a single defect in the tegmen of the temporal bone [1] .…”

Section: Introductionmentioning

confidence: 98%

Conductive Hearing Loss as the Initial Manifestation of Spontaneous Herniation of Epitympanic Meningocele

Kuo¹,

Wang²,

Feng³

et al. 2014

Int Adv Otol

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Although the incidence of tegmen tympani dehiscence is relatively high, diagnosis can be difficult if there are no clinical clues or a high degree of suspicion. We describe the case of a 79-year-old male patient with progressive left-sided hearing impairment and ear ringing for 1 year who was eventually diagnosed with middle ear meningocele. Audiometry showed conductive hearing loss with an air-bone gap of 20 dB. This was caused by impaired mobility of the ossicular chain due to meningocele herniation from the dehiscence of the tegmen tympani. In the absence of typical symptoms, such as cerebrospinal fluid middle ear effusion and otorrhoea, diagnosis of tegmen tympani dehiscence may be challenging. Consequently, tegmen tympani dehiscence should be included in the differential diagnosis of conductive hearing loss, which may be the only or early clinical manifestation of tegmen tympani dehiscence. High clinical suspicion and fully assessment are necessary to prevent misdiagnosis and further serious complications. KEY WORDS: Tegmen tympani, dehiscence, meningocele, conductive hearing loss INTRODUCTIONThe tegmen tympani is a thin bony plate that separates the cranial and tympanic cavities. Dehiscence of the tegmen tympani may be accompanied by herniation of the meninges or brain (meningocele or meningoencephalocele). The findings from an autopsy study suggest that 15% to 34% of specimens contain a single defect in the tegmen of the temporal bone

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“…Since then, a variety of terms such as brain hernia, brain fungus, brain prolapse, cerebral hernia, fungus cerebri, meningo-encephalocoele or encephalocoele have been used to describe this condition 1 . The etiology of brain herniation has been attributed to temporal bone trauma, iatrogenic injuries, cholesteatoma, chronic otitis media, congenital cranial base defect, arachnoid granulations, neoplasia, irradiation and idiopathic causes [2][3][4][5][6]. Of these, injuries to tegmen and dura by cutting burr during mastoid surgery are probably the commonest cause.…”

Section: Introductionmentioning

confidence: 99%

Meningo-encephalocoele of temporal lobe-management by blind SAC closure

Ramalingam

Murthy

et al. 2009

Indian J Otolaryngol Head Neck Surg

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Brain herniation into the middle ear and mastoid is rare but is a described complication of chronic ear disease. The diagnosis is mainly clinical and requires a high index of suspicion. This can be confi rmed by imaging studies. Different surgical modalities have been described in managing this condition. We present a case managed by combined trans-mastoid mini-craniotomy approach and blind sac closure.

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Diagnosis and Management of Spontaneous Cerebrospinal Fluid‐Middle Ear Effusion and Otorrhea

Cited by 140 publications

References 6 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

Conductive Hearing Loss as the Initial Manifestation of Spontaneous Herniation of Epitympanic Meningocele

Meningo-encephalocoele of temporal lobe-management by blind SAC closure

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