Adult onset spontaneous CSF otorrhea with oval window fistula and recurrent meningitis: MRI findings

In Patients with Unexplained Non-Epidemic Recurrent Meningitis a Direct Communication between the Subarachnoid Space and the Outside Must Be Sough

Cerebrospinal fluid (CSF) rhinorrhea is not an uncommon condition, and it may lead to recurrent attacks of meningitis. The detection of the leakage site is an essential part of the investigations performed for the patient. In some cases, an anterior skull base site cannot be detected despite continuous leakage. In these cases, a more distal site must be sought. Furthermore, in some cases, the leakage occurs in the temporal bone. In such patients, a history of hearing loss or previous ear complaints indicates a hidden CSF otorhinorrhea. We present two adult cases of congenital hearing loss due to unilateral inner ear anomalies who presented later in life with repeated meningitis attacks and CSF otorhinorrhea.

Simultaneous repair of cerebrospinal fluid otorrhea and cochlear implantation in two patients with recurrent meningitis and severe inner ear malformation

OBJECTIVES

To investigate the outcomes of simultaneous cochlear implantation and repair of a cerebrospinal fluid (CSF) leak in two patients with inner ear malformations following meningitis.

METHODS

In this retrospective study and review of the literature, two patients with recurrent meningitis and severe inner ear malformation underwent cochlear implantation via the round window, and repair of CSF otorrhea via a transmastoid lateral semicircular canal approach. Both patients were treated with antibiotics for 7 days after the surgery.

RESULTS

Neither patient has exhibited evidence of CSF otorrhea 1 year after surgical repair. Categorical Auditory Performance (CAP) scores and the Speech Intelligibility Ratings (SIRs) were obtained before and 1 year after surgery: the scores were 0 versus 4 and 0 versus 2, respectively. Vestibular function tests of both patients were reviewed and were normal.

CONCLUSION

Simultaneous repair of CSF otorrhea and cochlear implantation in patients with recurrent meningitis and severe inner ear malformation can be regarded as safe and effective.

Novel radiographic measurement algorithm demonstrating a link between obesity and lateral skull base attenuation

OBJECTIVES

(1) To describe a validated algorithm for measuring tegmen thickness on computed tomography scans. (2) To compare the tegmen thickness in 3 groups: patients with spontaneous cerebrospinal fluid (CSF) leaks, obese controls, and nonobese controls.

STUDY DESIGN

Retrospective review.

SETTING

Patients with spontaneous CSF otorrhea often have highly attenuated tegmen plates. This is associated with obesity and/or idiopathic intracranial hypertension (IIH). No evidence exists, however, that objectively links obesity and/or IIH with skull base attenuation.

SUBJECTS AND METHODS

This was a retrospective review from 2004 to the present. Patients with spontaneous CSF otorrhea and matched obese (body mass index [BMI] >30 kg/m(2)) and nonobese (BMI <30 kg/m(2)) controls were selected. Tegmen thickness was measured radiographically. Interrater validity was assessed.

RESULTS

Ninety-eight patients were measured: 37 in the CSF group (BMI, 36.6 kg/m(2)), 30 in the obese group (BMI, 34.6 kg/m(2)), and 31 in the nonobese group (BMI, 24.2 kg/m(2)). The CSF group had a significantly thinner tegmen compared to both the obese control (P < .01) and nonobese control (P = .0004) groups. Obese controls had a thinner tegmen than nonobese controls (P < .00001). A significant inverse correlation was detected between skull base thickness and BMI. Signs/symptoms of IIH were most commonly found in the CSF group. Good to very good strength of agreement was detected for measures between raters.

CONCLUSION

This is the first study to (1) quantify lateral skull base thickness and (2) significantly correlate obesity with lateral skull base attenuation. Patients who are obese with spontaneous CSF leaks have greater attenuation of their skull base than matched obese controls. This finding supports theories that an additional process, possibly congenital, has a pathoetiological role in skull base dehiscence.

Congenital Perilymph Fistula Causing Recurrent Meningitis

Objective

To study the steps involved in definitive evaluation and successful management of patients with congenital perilymph fistula presenting with recurrent meningitis.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

The case records of 11 patients (12 ears) treated for congenital perilymph fistula presenting with recurrent meningitis were reviewed to ascertain their clinical, radiological, and intraoperative features and outcome following surgery.

Results

Most patients presented after at least 3 episodes of meningitis (range, 2-10 episodes). Ipsilateral hearing loss was present in 9 of 12 ears, with normal hearing in 3 patients. High-resolution computed tomography and/or magnetic resonance imaging scanning of the temporal bone contributed to the diagnosis in 75% of cases but was normal in 3 cases (25%). Oval window and round window defects were the most common (66.7% and 63.6%, respectively). Four ears (33.3%) had more than 1 defect. The unusual presentations included 2 patients who presented in adulthood, a patient with a defect in the medial wall of the attic, and 3 patients with normal radiological findings. Follow-up ranged from 1 to 11 years (median, 2 years). There were 2 failures following simple fistula closure with cessation of symptoms after vestibular obliteration. No patient was readmitted with recurrent meningitis after definitive surgery.

Conclusion

Up to 25% of patients with recurrent meningitis secondary to congenital perilymph fistula may have normal audiological and radiological assessment necessitating exploratory tympanotomy. Vestibular obliteration, rather than simple fistula closure, prevents recurrence.

New considerations in the cause of spontaneous cerebrospinal fluid otorrhea

OBJECTIVE

To examine the demographic and radiographic features of patients with spontaneous cerebrospinal fluid otorrhea and to determine whether they display similar characteristics to patients with idiopathic intracranial hypertension.

STUDY DESIGN

Retrospective case review.

SETTING

Academic, tertiary referral center.

PATIENTS

All individuals presenting with spontaneous cerebrospinal fluid otorrhea, diagnosed between 2000 and 2009, undergoing primary surgical repair.

INTERVENTIONS

All patients underwent surgical repair via a transmastoid, middle fossa, or combined transmastoid-middle fossa approach.

MAIN OUTCOME MEASURES

Patient demographics such as age, race, sex, height, weight, and body mass index, the presence of a radiographically empty or partially empty sella, and preoperative radiographic and intraoperative surgical findings of the temporal bone.

RESULTS

Twenty-three patients underwent primary surgical repair for spontaneous cerebrospinal fluid otorrhea. Fifteen patients underwent preoperative magnetic resonance imaging of the head with 12 (80%) demonstrating the presence of an empty or partially empty sella. Mean body mass index of those patients with an empty or partially empty sella was 38.0 kg/m2 compared with 28.5 kg/m2 for those without an empty sella.

CONCLUSION

Patients with spontaneous cerebrospinal fluid otorrhea are often middle-aged and obese, with females being affected nearly twice as often as males. Empty or partially empty sella was observed in 80% of patients with spontaneous cerebrospinal fluid otorrhea as demonstrated by preoperative magnetic resonance imaging. Patients with spontaneous cerebrospinal fluid otorrhea who display these demographic and radiographic features should be further evaluated for the presence of idiopathic intracranial hypertension.

Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis

Recurrent bacterial meningitis is a rare phenomenon and generally poses a considerable diagnostic challenge to the clinician. Ultimately, a structured approach and early diagnosis of any underlying pathology are crucial to prevent further episodes and improve the overall outcome for the affected individual. In this article, we are reviewing the existing literature on this topic over the last two decades, encompassing 363 cases of recurrent bacterial meningitis described in 144 publications. Of these cases, 214 (59%) were related to anatomical problems, 132 (36%) were related to immunodeficiencies, and 17 (5%) were related to parameningeal infections. The review includes a detailed discussion of the underlying pathologies and microbiological aspects as well as recommendations for appropriate diagnostic pathways for investigating this unusual entity.

Diagnosis and management of spontaneous cerebrospinal fluid otorrhea

OBJECTIVE

To describe the clinical presentation, diagnosis, surgical management, and outcome of patients with spontaneous cerebrospinal fluid otorrhea.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

METHODS

The authors conducted a chart review of all previously unreported cases of surgically confirmed cerebrospinal fluid otorrhea at their institution between September 1996 and February 2005. Acquired cases were excluded from this study. Eleven cases of spontaneous cerebrospinal fluid otorrhea were identified among 10 patients.

RESULTS

Nine of the 10 patients presenting with spontaneous cerebrospinal fluid otorrhea were women. Ages ranged from 34 to 79 years. Eight patients presented with serous otitis media, and two women presented with meningitis. High-resolution computed tomography demonstrated a tegmen defect with a sensitivity of 80%. Nine tegmen defects were repaired using a transmastoid approach without recurrence. One patient with a contracted mastoid and a meningoencephalocele herniating from the tegmen tympani into the attic required the temporal craniotomy approach for definitive repair. Another patient with a tegmen tympani defect developed a recurrence of cerebrospinal fluid otorrhea 8 years after a transmastoid repair using only fascia and fibrin glue. A recurrent tegmen defect in this patient was repaired using a transmastoid approach and a multilayered closure technique.

CONCLUSION

The diagnosis of spontaneous cerebrospinal fluid otorrhea requires clinical suspicion in the setting of persistent serous otitis media. High-resolution computed tomography can confirm the diagnosis. The authors' findings indicate that repair through a transmastoid approach is effective if the tegmen defect can be widely visualized. The authors advocate a multilayered closure technique.