Idiopathic temporal bone encephaloceles in the obese patient

Scurry, W. Cooper; Ort, Stuart A.; Peterson, William M.; Sheehan, Jonas M.; Isaacson, Jon E.

doi:10.1016/j.otohns.2006.11.036

Cited by 62 publications

(66 citation statements)

References 17 publications

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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.…”

mentioning

confidence: 56%

“…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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confidence: 56%

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%

“…This has been noted by several authors, particularly in patients with spontaneous CSF leaks and idiopathic intracranial hypertension. 7,12,17,21,22 It has been demonstrated that intraabdominal pressure in obese patients is elevated and that this in turn translates into higher intrathoracic and cardiac filling pressures, thus decreasing venous return from the brain and ultimately increasing ICP. 22 Some have postulated that the increased amount of estrogen produced by adipose tissue in obese patients may play a role in the development of elevated ICP-abnormally high levels of estrogen have been found in the CSF of obese patients with idiopathic intracranial hypertension.…”

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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“…6,7,[10][11][12]15 As the middle fossa cranial base develops progressively enlarging defects, CSF pulsations contribute to dehiscence and can lead to meningoencephalocele development and eventual dural disruption. 4,8,12,16 This sequence of events results in effusions in the middle ear and mastoid air cells that can manifest as CSF fistulas, through a disrupted tympanic membrane or via the eustachian tube. [1][2][3]5,11,12,15 Given that intracranial hypertension has been implicated as a significant factor in temporal encephalocele formation, 7,[10][11][12]15 we hoped to clarify this correlation by reviewing a series of tegmen defects repaired surgically and the associated ICP measurements in these patients.…”

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confidence: 99%

Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

Kenning¹,

Willcox²,

Artz³

et al. 2012

FOC

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Object Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors. Methods The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect. Results The average body mass index (BMI) among all patients was 33.2 ± 7.2 kg/m2. Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m2). Preoperative intracranial pressures (ICPs) averaged 21.8 ± 6.0 cm H2O, with 10 patients (43%) demonstrating an ICP > 20 cm H2O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months). Conclusions Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H2O, BMI > 30 kg/m2, preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth).

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Idiopathic temporal bone encephaloceles in the obese patient

Abstract: TBE is associated with morbid obesity in our population and should be considered in the differential diagnosis when evaluating mastoid and middle ear disease in the morbidly obese.

Cited by 62 publications

References 17 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?

Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

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