Repair of Middle Fossa CSF Using Novel Materials
Repair of Middle Fossa CSF Using Novel Materials
The demographic information of patients included in this investigation is summarized in Table 1. A total of 8 patients underwent operative repair of MFCSF leaks. One patient younger than age 18 years was excluded. No conservative therapies were attempted at our institution before surgical management. The sex was evenly distributed with 3 men and 4 women. Patients ranged in age from 22 to 81 years (mean 53 years). In 5 patients (71.4%) MFCSF leakage was acquired, and in 2 (28.6%) it was spontaneous. The most common presenting symptoms were otorrhea in 4 patients (57.1%) and hearing loss in 3 (48.9%). Only 1 patient (14.3%) exhibited CSF rhinorrhea. Six patients (85.7%) had defects of the tegmen tympani and 1 patient (14.3%) had a defect of the sphenoid bone. The mean bony defect was 6 mm (range 4–7 mm) on CT imaging. The size of the bony defects was not recorded in the operative notes. Two patients (28.6%) had a history of chronic otitis media and 5 patients (71.4%) had a history of previous otological surgical procedures.
All patients underwent a middle fossa approach after placement of a lumbar drain at the start of the operation. Postoperatively, lumbar drainage was continued for 3–5 days. The mean duration of drainage was 4.2 days, and the mean volume of CSF drained was 1052 ml (range 680–1658 ml). The mean operative time was 202 minutes (range 175–223 minutes), and the mean blood loss was 370 ml (range 50–1200 ml).
In all repair procedures, we used the combination of HAC, collagen-based dural substitute matrix, and PEG hydrogel sealant. Other materials used to augment the closure included split-thickness bone grafts and temporalis fascia and muscle (Table 2). Split-thickness bone grafts were used in addition to HAC to repair the temporal bone defect in 4 cases (57.1%). Dural substitute matrix was used for dural repair and was placed as either an onlay (2 patients [28.5%]) or an inlay/onlay (5 patients [71.4%]). The addition of temporalis muscle and fascia for dural defect repair was used in 4 cases (57.1%). Encephaloceles were identified and repaired in 5 (71.4%) of the 7 cases.
The mean follow-up duration was 12 months (range 5–33 months), and all patients were free of evidence of MFCSF leak, wound infections, or signs of neurovascular deficits at final follow-up appointment. Hearing loss improved in only 1 patient with preoperative hearing loss, whereas in the other 2 patients hearing status remained unchanged.
One patient returned to the hospital on postoperative Day 8 with an epidural hematoma requiring surgical evacuation. Intraoperatively, the repair site was inspected and showed no signs of CSF leakage. This patient was discharged to home without further complications. A second patient experienced a superficial wound dehiscence 48 days postoperatively without evidence of CSF fistula. The majority of our patients (71.4%) experienced no postoperative complications. The data are included in Table 2.
Results
Patient Population
The demographic information of patients included in this investigation is summarized in Table 1. A total of 8 patients underwent operative repair of MFCSF leaks. One patient younger than age 18 years was excluded. No conservative therapies were attempted at our institution before surgical management. The sex was evenly distributed with 3 men and 4 women. Patients ranged in age from 22 to 81 years (mean 53 years). In 5 patients (71.4%) MFCSF leakage was acquired, and in 2 (28.6%) it was spontaneous. The most common presenting symptoms were otorrhea in 4 patients (57.1%) and hearing loss in 3 (48.9%). Only 1 patient (14.3%) exhibited CSF rhinorrhea. Six patients (85.7%) had defects of the tegmen tympani and 1 patient (14.3%) had a defect of the sphenoid bone. The mean bony defect was 6 mm (range 4–7 mm) on CT imaging. The size of the bony defects was not recorded in the operative notes. Two patients (28.6%) had a history of chronic otitis media and 5 patients (71.4%) had a history of previous otological surgical procedures.
Surgical Data
All patients underwent a middle fossa approach after placement of a lumbar drain at the start of the operation. Postoperatively, lumbar drainage was continued for 3–5 days. The mean duration of drainage was 4.2 days, and the mean volume of CSF drained was 1052 ml (range 680–1658 ml). The mean operative time was 202 minutes (range 175–223 minutes), and the mean blood loss was 370 ml (range 50–1200 ml).
In all repair procedures, we used the combination of HAC, collagen-based dural substitute matrix, and PEG hydrogel sealant. Other materials used to augment the closure included split-thickness bone grafts and temporalis fascia and muscle (Table 2). Split-thickness bone grafts were used in addition to HAC to repair the temporal bone defect in 4 cases (57.1%). Dural substitute matrix was used for dural repair and was placed as either an onlay (2 patients [28.5%]) or an inlay/onlay (5 patients [71.4%]). The addition of temporalis muscle and fascia for dural defect repair was used in 4 cases (57.1%). Encephaloceles were identified and repaired in 5 (71.4%) of the 7 cases.
Postoperative Results and Complications
The mean follow-up duration was 12 months (range 5–33 months), and all patients were free of evidence of MFCSF leak, wound infections, or signs of neurovascular deficits at final follow-up appointment. Hearing loss improved in only 1 patient with preoperative hearing loss, whereas in the other 2 patients hearing status remained unchanged.
One patient returned to the hospital on postoperative Day 8 with an epidural hematoma requiring surgical evacuation. Intraoperatively, the repair site was inspected and showed no signs of CSF leakage. This patient was discharged to home without further complications. A second patient experienced a superficial wound dehiscence 48 days postoperatively without evidence of CSF fistula. The majority of our patients (71.4%) experienced no postoperative complications. The data are included in Table 2.
Source...