Transmastoid extradural–intracranial approach for repair of transtemporal meningoencephalocele: A review of 31 consecutive cases

Semaan, Maroun T.; Gilpin, David; Hsu, Daniel P.; Wasman, Jay; Megerian, Cliff A.

doi:10.1002/lary.21887

Cited by 80 publications

(65 citation statements)

References 26 publications

(34 reference statements)

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“…With a combined mastoid/middle fossa approach, we were able to achieve a high success rate (96%) of CSF fistula closure, comparable to rates in previously published reports. 2,5,8,13,14 Our surgical technique involves a robust dural closure following extradural dissection and encephalocele reduction/resection. We use a multilayer closure for direct repair of the dural and cranial base defects.…”

Section: Patient Outcomesmentioning

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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Section: Patient Outcomesmentioning

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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show abstract

“…15,20,21,23 Proponents of the transmastoid approach cite minimized morbidity, the option of concurrent ossiculoplasty, access to tegmen and posterior fossa plate without brain retraction, and earlier hospital discharge. However, a contracted mastoid, anterior sigmoid, lowlying tegmen, or large encephalocele may limit access to the mastoid and tympanic space.…”

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

113

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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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“…There were several possible surgical treatments, including a middle fossa craniotomy alone, a middle cranial fossa approach, a transmastoid approach, and a combined middle cranial fossa/transmastoid approach [10][11][12][13]. The choice of surgical approach should be driven by the etiology of the defect, the site and extent of the bony defect and the brain hernia, the type and degree of hearing loss, the presence of chronic infection in the middle ear, and the intraoperative finding of active CSF leakage.…”

Section: Discussionmentioning

confidence: 99%

Assessment and Treatment of Spontaneous Temporal Bone Meningoencephalocele for Hearing Gain

Lee¹,

Ku²,

Park³

et al. 2015

Int J Otorhinolaryngol

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Transmastoid extradural–intracranial approach for repair of transtemporal meningoencephalocele: A review of 31 consecutive cases

Abstract: The TMEDIC is a safe and effective method to repair transtemporal meningoencephalocele obviating the need for a middle fossa craniotomy in certain cases.

Cited by 80 publications

References 26 publications

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

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

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

Assessment and Treatment of Spontaneous Temporal Bone Meningoencephalocele for Hearing Gain

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