Repair of Middle Fossa CSF Using Novel Materials
Repair of Middle Fossa CSF Using Novel Materials
This 22-year-old man presented with right-sided conductive hearing loss and otorrhea following aborted OCR by the otolaryngology service. The patient had been seen by our service 3 years prior when profound CSF rhinorrhea developed following a motor vehicle collision. At that time, the patient had undergone repair of an anterior fossa floor with acceptable immediate results. However, intermittent rhinorrhea recurred. At 5 months postoperatively, a right-sided ventriculoperitoneal shunt was placed to control the symptoms. The patient subsequently developed signs and symptoms of hearing loss, was referred to the otolaryngology service, and was scheduled for an OCR. During the approach portion of the OCR, an encephalocele was encountered and the surgery was aborted. The patient subsequently developed right-sided CSF otorrhea, prompting a temporal bone CT scan, which revealed fluid in the right mastoid air cells and middle ear, as well as a defect in the tegmen tympani (Fig. 2).
(Enlarge Image)
Figure 2.
Coronal CT scan showing a defect of the right tegmen (arrow) with fluid in the middle ear.
The patient then consented to undergo a right middle fossa approach and repair of the defect (Video 1).
Video 1. Clip showing right-sided intraoperative repair of an MFCSF leak, using an inlay/onlay dural graft technique, PEG hydrogel sealant, and HAC. Click here to view with Media Player. Click here to view with Quicktime.
Prior to positioning, a lumbar drain and right-sided facial nerve monitor were placed. The craniotomy was performed as described in Methods; following extradural dissection and temporal lobe retraction, a 2-cm defect was identified in the tegmen concurrent with a breach in the basal aspect of the temporal dura mater. A small piece of dural substitute was placed inside the dural opening abutting the temporal lobe, and a second piece was placed as an onlay. The edges were successfully sealed with PEG hydrogel sealant, and the bony defect was remodeled with HAC. The patient tolerated the procedure well and recovered in the intensive care unit for 5 days while CSF was diverted continuously at 10 ml/hour. He was discharged to home 1 day following the removal of his lumbar catheter. At his last follow-up, over 30 months postoperatively, he remains free of CSF leakage.
Illustrative Case
This 22-year-old man presented with right-sided conductive hearing loss and otorrhea following aborted OCR by the otolaryngology service. The patient had been seen by our service 3 years prior when profound CSF rhinorrhea developed following a motor vehicle collision. At that time, the patient had undergone repair of an anterior fossa floor with acceptable immediate results. However, intermittent rhinorrhea recurred. At 5 months postoperatively, a right-sided ventriculoperitoneal shunt was placed to control the symptoms. The patient subsequently developed signs and symptoms of hearing loss, was referred to the otolaryngology service, and was scheduled for an OCR. During the approach portion of the OCR, an encephalocele was encountered and the surgery was aborted. The patient subsequently developed right-sided CSF otorrhea, prompting a temporal bone CT scan, which revealed fluid in the right mastoid air cells and middle ear, as well as a defect in the tegmen tympani (Fig. 2).
(Enlarge Image)
Figure 2.
Coronal CT scan showing a defect of the right tegmen (arrow) with fluid in the middle ear.
The patient then consented to undergo a right middle fossa approach and repair of the defect (Video 1).
Video 1. Clip showing right-sided intraoperative repair of an MFCSF leak, using an inlay/onlay dural graft technique, PEG hydrogel sealant, and HAC. Click here to view with Media Player. Click here to view with Quicktime.
Prior to positioning, a lumbar drain and right-sided facial nerve monitor were placed. The craniotomy was performed as described in Methods; following extradural dissection and temporal lobe retraction, a 2-cm defect was identified in the tegmen concurrent with a breach in the basal aspect of the temporal dura mater. A small piece of dural substitute was placed inside the dural opening abutting the temporal lobe, and a second piece was placed as an onlay. The edges were successfully sealed with PEG hydrogel sealant, and the bony defect was remodeled with HAC. The patient tolerated the procedure well and recovered in the intensive care unit for 5 days while CSF was diverted continuously at 10 ml/hour. He was discharged to home 1 day following the removal of his lumbar catheter. At his last follow-up, over 30 months postoperatively, he remains free of CSF leakage.
