Congenital cerebrospinal otorrhea

Challenges in the Management of Symptomatic Fallopian Canal Meningoceles: A Multicenter Case Series and Literature Review

OBJECTIVE

To describe the presentations, the diagnosis, our treatment approaches, and the outcomes for 11 patients with fallopian canal meningocele (FCM).

STUDY DESIGN MULTICENTER

Retrospective case series.

SETTING

Tertiary referral centers.

PATIENTS

Patients (N = 11) with radiographically or intraoperatively identified, symptomatic FCM.

INTERVENTIONS

Surgical repair of cerebrospinal fluid (CSF) leak and meningocele versus observation.

MAIN OUTCOME MEASURES

Presentation (including symptoms, radiographic imaging, and comorbidities), management (including surgical approach, technique for packing, use of lumbar drain), clinical outcomes (control of CSF leak, meningitis, facial nerve function), and revision surgery.

RESULTS

Patients presented with spontaneous CSF leak (n = 7), conductive (N = 11) and sensorineural hearing loss (n = 3), nonpositional intermittent vertigo (n = 3), headaches (n = 4), and recurrent meningitis (n = 1). Risk factors in our series included obesity (n = 4), Chiari 1 malformation (n = 1), and head trauma (n = 2). Noncontrast computed tomography of the temporal bone and magnetic resonance imaging were positive for FCM in 10 patients. Eight patients were managed surgically via a transmastoid approach (n = 4), combined transmastoid and middle fossa (N = 3), or middle fossa alone (n = 1); three were managed conservatively with observation. Postoperative complications included worsened facial nerve palsy (n = 1), recurrent meningitis (n = 1), and persistent CSF leak that necessitated revision (n = 1).

CONCLUSIONS

Facial nerve meningoceles are rare with variable presentation, often including CSF otorrhea. Management can be challenging and guided by symptomatology and comorbidities. Risk factors for FCM include obesity and head trauma, and Chiari 1 malformation may present with nonspecific otologic symptoms, in some cases, meningitis and facial palsy. Layered surgical repair leads to high rates of success; however, this may be complicated by worsening facial palsy.

Management of Fallopian Canal Spontaneous CSF Leaks, Implications of Elevated Intracranial Pressure: Case Report and Systematic Review of the Literature

OBJECTIVES

Describe the diagnosis and management of a spontaneous cerebrospinal fluid leak (sCSF-L) through the facial nerve fallopian canal and determine the role of intracranial hypertension (IH).

STUDY DESIGN

Retrospective case study and systematic review of the literature.

METHODS

Reviewed patient characteristics, radiographic findings, and management of the facial nerve canal CSF leak and postoperative IH. Conducted systematic literature review according to the PRISMA guidelines for surgical management and rates of IH.

RESULTS

A 50-year-old female with bilateral tegmen defects and temporal encephaloceles underwent left middle cranial fossa (MCF) repair. Intraoperative CSF egressed from the temporal bone tegmen defects. Facial nerve decompression revealed CSF leak from the labyrinthine segment. A nonocclusive temporalis muscle plug was placed in the fallopian canal, and tegmen repair was completed with bone cement. A ventriculoperitoneal shunt was placed for IH. Postoperative facial nerve function and hearing were normal. A total of 20 studies met inclusion criteria with a total of 25 unique patients. Of 13 total adult cases of fallopian canal CSF leak, there is a 46% recurrence rate, and 86% of patients had documented IH when tested.

CONCLUSIONS

Fallopian canal CSF leaks are rare and challenging to manage. Assessment of intracranial hypertension and CSF diversion is recommended along with MCF skull base repair to preserve facial nerve function and conductive hearing.

Fallopian Canal Meningocele Causing Cerebrospinal Fluid Rhinorrhoea

Fallopian canal meningocele is an extremely rare cause of cerebrospinal fluid rhinorrhoea. Also, due to complex anatomical relations and a lack of experience, its management remains a challenge. Here we report a case focusing on its clinical course, radiological features, and management.

Cerebrospinal Fluid Otorrhea After a Routine Tympanostomy Tube Placement: A Review of the Literature on Hyrtl Fissure

OBJECTIVE

To review the literature on Hyrtl fissure (HF) and contribute our experience with a 2-year old who developed cerebrospinal fluid (CSF) otorrhea during routine tympanostomy tube placement.

METHODS

Data Sources: Pubmed and Google Scholar searches were conducted of articles in the English language literature from all time periods using the words Hyrtl, Hyrtl's fissure, HF, and tympanomeningeal fissure. Study Selection: All relevant articles were reviewed to identify cases of HF.

RESULTS

Data Extraction: Nineteen cases, including ours, are described. Patient characteristics, method(s) of diagnosis and repair, and outcomes are reported. Computed tomography and intraoperative endoscopic images from our case are included. Presentation is more common in children (66.7% of cases where age was stated, n = 10) than in adults (33.3%, n = 5), and is most commonly unilateral (89.5%, n = 17). Cerebrospinal fluid otorrhea was the most common presentation. Six were discovered after tympanostomy tube placements while 3 were identified during cochlear implant work-up or after device failure. Surgical approaches described include endaural, transcanal, retrosigmoid, postauricular, and posterior fossa endoscopic. Multiple materials including bone wax, bone pate, fascia, muscle, and tissue sealant have been used. Our case describes an endoscopic repair in a child, which was successful at a 2-year follow-up. Data Synthesis: The small number of cases limits the utility of statistical analysis (n = 19).

CONCLUSIONS

Hyrtl fissure is a rare but important entity that may be discovered when routine procedures have unexpected results. Hyrtl fissure should be included in the differential diagnosis when there is persistent clear otorrhea after a tympanostomy tube, cochlear implant misinsertion, meningitis, or unexplained middle ear effusion in an adult.

Spontaneous Congenital Perilabyrinthine Cerebrospinal Fluid Fistulas

OBJECTIVES

To report a recalcitrant spontaneous cerebrospinal fluid (CSF) fistula arising from multiple, anatomically-linked lateral skull base defects, and to review the available literature to determine optimal techniques for operative repair of congenital CSF fistulae.

METHODS

A patient with recurrent episodes of otologic meningitis was found to have a patent tympanomeningeal fissure, also known as a Hyrtl's fissure, and internal auditory canal (IAC) diverticulum that communicated with the jugular bulb. A systematic review of the literature characterized all reports of spontaneous congenital perilabyrinthine CSF leaks, and all cases of Hyrtl's fissures.

RESULTS

An 11-year-old female was referred for recurrent meningitis. Imaging demonstrated a fistulous connection between the middle ear and IAC diverticulum via the jugular foramen. Specifically, a Hyrtl's fissure was identified, as well as demineralized bone around the jugular bulb. Obliteration of the fissure was initially performed, and a fistula reformed 4 months later. Multifocal CSF egress in the hypotympanum was identified on re-exploration, and middle ear obliteration with external auditory canal (EAC) overclosure was performed. A systematic review of the literature demonstrated 19 cases of spontaneous congenital perilabyrinthine CSF leaks. In total, 6 cases had multiple sources of CSF leak and 2 had history suggestive of intracranial hypertension. All of these noted cases demonstrated leak recurrence. Middle ear obliteration with EAC overclosure was successful in 4 recalcitrant cases.

CONCLUSIONS

Repair of spontaneous congenital perilabyrinthine CSF leaks in cases demonstrating multiple sources of egress or signs of intracranial hypertension should be approached with caution. Middle ear obliteration with EAC overclosure may provide the most definitive management option for these patients, particularly if initial attempt at primary repair is unsuccessful.

Perigeniculate arachnoid cysts and CSF fistulae of the fallopian canal: Histopathologic correlates of a rare clinical entity

Cerebrospinal fluid (CSF) fistulae originating from the fallopian canal of the facial nerve is hypothesized to arise due to atypical patterns of subarachnoid space extension into the geniculate ganglion or more distal regions along the intratemporal course of the facial nerve, but its pathogenesis remains poorly understood. Although a rare etiology of CSF fistulae of the temporal bone, there are significant clinical ramifications due to the risk of recurrent meningitis, difficulty in identifying the anatomic location of the CSF leak, and technical challenges associated with surgical repair. We present three clinical cases of arachnoid cysts within the geniculate fossa with or without CSF fistulization and provide histopathologic correlates of this rare clinical phenomenon from a human temporal bone collection. The pediatric and adult patients presented suggest differential pathophysiologic mechanisms associated with CSF fistulae. Temporal bone histology reveals atypical patterns of subarachnoid space extension in the fallopian canal that may underlie arachnoid cyst formation and overt CSF leak from the geniculate region.

Fallopian Canal Meningocele with Spontaneous Cerebrospinal Fluid Otorrhea: Case Report and Systematic Review of the Literature

OBJECTIVE

To present a case of spontaneous cerebrospinal fluid (CSF) otorrhea from a fallopian canal meningocele involving the geniculate fossa and review all cases of fallopian canal CSF leak reported in the literature with discussion of management and outcomes.

METHODS

A 53-year-old woman with history of morbid obesity and hypertension presented to a tertiary care referral center with unilateral high-volume CSF otorrhea. High-resolution temporal bone computed tomography demonstrated significant dilatation of the geniculate fossa. Rates of postoperative facial paralysis and refractory CSF leak were reported for the present case and prior cases reported in the literature.

RESULTS

Locations of fallopian canal dehiscence, surgical approaches, techniques for packing dehiscence, rates of postoperative facial paralysis and CSF leak, and revision procedures were reported for the present case and 14 cases in the literature. The present case involved dehiscence of the geniculate fossa that was approached via combined transmastoid-middle cranial fossa exploration with facial nerve monitoring. The area of dehiscence was carefully packed with temporalis fascia, muscle, and artificial dural substitute overlay to repair the CSF leak without injuring the facial nerve. Postoperatively, no facial weakness was noted; however, right-sided high-volume CSF otorrhea persisted. After discussing treatment options, the patient underwent subtotal petrosectomy and blind-sac closure of the external auditory canal the following day. This successfully resolved the CSF leak without causing facial nerve weakness.

CONCLUSIONS

Fallopian canal meningocele is an exceedingly rare cause of CSF otorrhea. Successful repair requires precise packing of the dilated facial canal to occlude the leak without injuring the facial nerve. For refractory CSF leak, subtotal petrosectomy and closure of the external auditory canal warrants consideration.

Postnatal development of the subarcuate fossa and subarcuate canaliculus-a computed tomographic study

PURPOSE

The subarcuate fossa (SF) is an anatomical structure situated on posterior wall of the petrous part of the temporal bone. In older children and adults, SF is a shallow depression and the subarcuate canaliculus starts within it. Awareness of postnatal changing morphology of this region is important especially for otosurgeon. The aim of this paper is to characterize both SF and SC by means of anatomical and radiological methods.

METHODS

The study was carried out on CT scans of 101 children, aged 1-60 months. Length of the pyramid (PL), the distance between the anterior semicircular canal (ASC) and the pyramidal apex (PLM), the outer diameter of ASC (ASCD), width under ASC (SFWM), the distance between the fundus of SF and ASC (SFLL), the maximal width of SF lateral to ASC (SFWL), the distance between the fundus of SF and posterior surface of the pyramid (SFL) were measured.

RESULTS

Average value of all measured distances: PL 52.14 ± 6.32 mm and PLM 25.73 ± 3.47 mm (raised with age); ASCD 8.63 ± 0.67 mm; SFWM 0.95 ± 1.24 mm; SFLL 1.07 ± 1.63 mm; SFWL 0.76 ± 1.19 mm; SFL 3.60 ± 2.50 mm.

CONCLUSIONS

Petrous part of the temporal bone grows with age up to 5 years old, whereas ASC does not. SF diminishes with age: lateral to ASC is well developed in newborns and infants (up to first year), rapidly diminishes in children aged 1-2 years and is totally absent in children > 2 years. SF medial to ASC is constant and diminishes with age. In children older than 3 years morphology of SF is similar to adult.

Mondini Dysplasia

Mondini dysplasia is characterized by a short flat cochlea, large vestibule, wide, small or missing semicircular canals, and immature sensorineural structures. It may occur in association with anomalies of other organs or it may occur in isolation. In some cases the footplate of the stapes is defective, leading to spontaneous perilymphatic fistula and meningitis.

Spontaneous resolution of cerebrospinal fluid otorrhoea in a patient with a Hyrtl's fissure

Objective:

This paper reports a rare case of cerebrospinal fluid leak due to a Hyrtl's fissure and discusses the non-operative management of the case.

Background and case report:

Cerebrospinal fluid otorrhoea is a rare phenomenon arising from an abnormal communicating tract between the subarachnoid space and middle ear. Affected patients are at a higher risk of developing meningitis and other neuro-otological complications. There are four common congenital causes of cerebrospinal fluid otorrhoea in the region of a normal labyrinth. This paper describes a case of cerebrospinal fluid in the middle ear resulting from a Hyrtl's fissure, which resolved spontaneously.

Conclusion:

A literature search indicated this to be the first case with such a resolution without the need for any intervention.

Spontaneous Cerebrospinal Fluid Otorrhea from a Persistent Tympanomeningeal Fissure Presenting as Recurrent Serous Otitis Media

We describe spontaneous cerebrospinal fluid (CSF) otorrhea through a patent tympanomeningeal (Hyrtl) fissure presenting as recurrent serous otitis media. The CSF leak was observed when a drain was placed through the tympanic membrane by an otologist. The diagnosis was then confirmed by computed tomography and magnetic resonance imaging, and the patient underwent a successful surgical treatment via a retrosigmoid approach. We describe the case and review causes of spontaneous CSF rhinorrhea/otorrhea.

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.

The Management of Spontaneous Otogenic CSF Leaks: A Presentation of Cases and Review of Literature

Objective The types of otogenic cerebrospinal fluid (CSF) fistulae were previously classified into defects through, adjacent to, or distal to the otic capsule. This article presents cases of the three different types of spontaneous CSF fistulae and reviews pertinent literature. We examine the management of the different types of otogenic CSF leaks with modern audiovestibular testing, imaging, and surgical techniques. Design Case series and review of the literature. Setting Academic tertiary neurotologic referral practice. Participants Four patients identified through a retrospective search. Main outcome measures Resolution of CSF leak and absence of meningitis. Results Surgical intervention was performed on the four cases described in this series; none had a return of CSF otorrhea in the postoperative period or meningitis. Conclusions Otogenic CSF fistulae may lead to life-threatening infection and in congenital forms are typically not diagnosed unless meningitis has occurred. Rapid and proper recognition, work-up, and treatment of such leaks decrease the risk of permanent neurologic sequelae as well as recurrent meningitis.

Spontaneous CSF otorrhoea - Presenting as conductive deafness

Spontaneous CSF otorrhea specially in older age is a rare condition. Congenital inner ear malformation is one of the commonest causes in pediatric age group and either because of trauma or spontaneously it comes out into middle ear. In pediatric age group usual presentation is with history of meningitis while adult patients may present as watery discharge from nose or ear. This is a case, presented with conducted deafness with negative middle ear pressure. Grommet was put presuming secretory otitis media but B2-transferrin levels of the secretion confirmed it as a CSF otorrhea. He was operated with past aural transmasioid approach. The defect was sealed in layers. Patient is in regular follow up is asymptomatic and without any recurrence.

Transmastoid approach to temporal bone cerebrospinal fluid leaks

PURPOSE

The aim of the study was to evaluate various presentations and treatment options for spontaneous cerebrospinal fluid (CSF) leakage originating in the temporal bone.

MATERIALS AND METHODS

Clinical data and imaging results for 18 ears (15 patients) presenting with spontaneous CSF leakage originating in the temporal bone were reviewed. Average follow-up period was 13.5 months. The main outcome measure was presence of persistent CSF leak postoperatively. A standard postauricular mastoidectomy was performed.

RESULTS

Fifteen patients diagnosed with spontaneous CSF leakage over an 8-year period including 3 treated for bilateral disease were included in the study. The age ranged between 33 and 83 years. Presenting symptoms included serous otitis media (44%), persistent otorrhea after tympanostomy tube placement (28%), and meningitis (28%). Preoperative diagnosis was made using imaging studies and was substantiated by observation of CSF leakage and dural herniation intraoperatively. Treatment was eustachian tube plugging (5%), mastoidectomy with fat obliteration (61%), middle fossa approach with extradural (17%), intradural repair (5%), or combined middle fossa and transmastoid (TM) approach (11%). Successful treatment was obtained in 17 of the 18 cases. The last 9 patients in the series underwent TM approach alone for repair with no treatment failures.

CONCLUSIONS

Repair of defects in tegmen mastoideum and posterior fossa can be successfully achieved on an outpatient basis without regard to size and multitude of defects via TM approach. This approach obviates the need for a craniotomy or lumbar drain.

Simultaneous cerebrospinal fluid otorrhea and rhinorrhea as a cause of recurrent meningitis in a patient with cochlear dysplasia

Inner ear dysplasia is a rare cause of cerebrospinal fluid otorhinorrhea and presents in a variety of ways, ranging from asymptomatic to recurrent bacterial meningitis. We describe a 6-year-old boy who presented with clear watery nasal discharge and recurrent bacterial meningitis. Magnetic resonance cisternogram showed cerebrospinal fluid leak through the cribriform plate of ethmoid. High-resolution computed tomographic scan of temporal bones confirmed the diagnosis of cochlear dysplasia, with cerebrospinal fluid leak coming through a defect near the oval window and through the eustachian tube orifice into the nose. Surgical closure of the defects was performed successfully.

CONCLUSION

Recurrent meningitis in a child should be investigated for inner ear malformations. Awareness of this condition, a high index of suspicion and early imaging can prevent complications and give excellent results in these children.

Arachnoid granulations of the temporal bone: a histologic study of dural and osseous penetration

HYPOTHESIS

Arachnoid granulations (AG) are more prevalent along the middle fossa surface of the temporal bone, where they produce larger bony defects than those occurring on the posterior surface.

BACKGROUND

Dural and bony defects formed by AGs are proposed to lead to spontaneous meningoencephaloceles and cerebrospinal fluid otorrhea. They most commonly occur at the tegmen and in individuals older than 40 years.

METHODS

Vertically sectioned temporal bones were evaluated using light microscopy to determine AG histology, distribution, and morphometry and to determine the prevalence of AG penetration in the donor population.

RESULTS

AGs were observed to penetrate the dura mater and make direct contact with cortical surfaces in 12.7% of donors in the Johns Hopkins Temporal Bone Collection. AGs occurred at middle fossa sites 13% more frequently than at posterior fossa sites. At middle fossa sites AGs produced significantly larger bony openings and were more likely to be associated with herniating brain tissue. Donors with AGs were significantly older, and all were in the late 30s or older.

CONCLUSION

Erosion of the temporal bone by AGs is not a rare occurrence in the population and becomes increasingly prevalent with age. It is estimated that 14 in 1,000 donors were at greatest risk of eventual cerebrospinal fluid leakage at the tegmen. The age and anatomic distribution described in this study strengthens the notion that AG penetration plays a role in the pathophysiology of spontaneous cerebrospinal fluid leaks and meningoencephaloceles of the temporal bone.

Evaluation and management of spontaneous temporal bone cerebrospinal fluid leaks

Spontaneous temporal bone cerebrospinal fluid leak may be defined as a leak without an apparent precipitating cause. These transdural fistulas occur rarely, and diagnosis is predicated upon a high index of suspicion. Leaks have been reported through both middle and posterior fossa defects, although the vast majority involve the middle fossa plate. In a previous study we reported 7 cases of spontaneous temporal bone cerebrospinal fluid leaks, all involving the middle fossa tegmen. Upon further review of these cases and 5 previously unreported cases, the defect was localized to the tegmen tympani in 9 of the total 12 cases. Diagnostic methods are discussed, with the importance of high-resolution computed tomography stressed. The role of contrast cisternography is also evaluated. An outline for surgical management is presented based upon residual hearing and defect location and accessibility. A transmastoid procedure offers the advantage of visualization of both the middle and posterior fossa plates, and this approach can be supplemented with an obliterative procedure when indicated. The middle fossa approach provides optimal exposure of the tegmen plate with less likelihood of ossicular injury when dealing with tegmen tympani defects. Adjuncts to surgical therapy include intrathecal fluorescein dye and continuous postoperative lumbar cerebrospinal fluid drainage.

Spontaneous cerebrospinal fluid leaks in congenital and acquired temporal bone defects-a long-term follow-up

Twelve patients presenting with tegmen defects and requiring surgical repair were retrospectively reviewed from 1982 to 1993. One half of the patients presented with a cerebrospinal fluid leak at some time in the course of their illness. Nine cases were considered to be acquired, secondary to previous mastoid surgery or trauma. All 9 had encephalocoeles. Three spontaneous leaks were considered congenital; 2 of these patients had encephalocoeles. This report represents a long-term follow-up of these cases, with an average follow-up of 7,6 years. Computed tomography and magnetic resonance imaging technology, as well as contrast studies, have tremendously aided in diagnosis and planning of surgical repair. Nine repairs were done through a dual transmastoid and middle fossa approach, with the other 3 done via a transmastoid approach only. We favored temporalis muscle flaps and temporalis fascia over synthetic materials for defect repairs. The long-term results and complications are discussed.

Spontaneous osteodural defects of the temporal bone: diagnosis and management of 12 cases

OBJECTIVES

The objectives of the study were to describe the clinical presentation, diagnostic process, surgical treatment, and outcome of patients with spontaneous dural defect of temporal bone and to explore the possible contribution of idiopathic intracranial hypertension.

METHODS

Medical records of consecutive patients with spontaneous defects of the temporal bone were reviewed. Clinical presentation, diagnostic process, exploration of benign intracranial hypertension, surgical management, and outcome of patients are presented.

RESULTS

Six of the 12 patients presenting with spontaneous cerebrospinal fluid otorrhea were women. Ages ranged from 38 to 76 years. Seven patients presented with meningitis. The location and the extent of the occurring defect were detected by computed tomography in all cases. Radiologic signs of empty sella syndrome, indicator of benign intracranial hypertension, were revealed in 3 cases using magnetic resonance imaging. Six tegmen defects were repaired using a middle fossa approach without recurrence. Four patients received the combined approach. All patients had complete resolution of the cerebrospinal fluid leak, although 2 cases developed adverse effects attributable to surgical procedure.

CONCLUSION

The diagnosis of spontaneous cerebrospinal fluid otorrhea requires clinical suspicion in the setting of meningitis and persistent serous otitis media. High-resolution computed tomography can confirm the diagnosis. The authors' findings advocate the multilayered closure technique through a middle fossa approach.

Spontaneous Temporal Cerebrospinal Fluid Leak

An abnormal communication between the subarachnoid spaces and the tympanic cavity and mastoid cells can determine a cerebrospinal fluid (CSF) leak in the air spaces of the temporal bone. The etiology of CFS leak in the temporal air cells includes acquired, congenital and spontaneous causes. Spontaneous CSF leak, defined as a leak without a manifest cause, is present in about 4% of cases and often occurs in the middle cranial fossa. We describe a case of spontaneous CSF leak in the right temporal air cells that mimicked a skull fracture in a subject with headache and apparent rhinorrhea after a head trauma. Both CT and MRI play a key role in the differential diagnosis between post-traumatic temporal CSF leak due to a fracture and spontaneous leak: traumatic CSF leak often does not require a surgical approach, whereas spontaneous CSF leak may need surgical treatment because of the risk of meningitis.

Meningocoele of fallopian canal causing recurrent meningitis

OBJECTIVE

We report a rare case of meningocoele of the fallopian canal resulting in recurrent meningitis.

METHODS

We present a case report together with a review of the world literature concerning meningocoele of the fallopian canal and meningitis.

RESULTS

A child developed profound, bilateral, sensorineural hearing loss as a result of meningitis caused by a meningocoele of the fallopian canal. He was treated with bilateral cochlear implantation, with a subtotal petrosectomy and middle ear and eustachian tube obliteration on the affected side.

CONCLUSION

Meningocoele of the fallopian canal has rarely been reported. This lesion can present with recurrent meningitis and, rarely, with facial weakness. All children with recurrent meningitis should be investigated for skull base defects. Treatment aims to prevent further episodes of meningitis; we recommend that this is best achieved by the technique of subtotal petrosectomy, with obliteration of the middle ear and eustachian tube.

Fallopian canal meningocele: report of two cases

OBJECTIVE

The purpose of this study is to report 2 rare cases of congenital fallopian canal meningoceles.

INTERVENTIONS

Magnetic resonance imaging, computed tomography (CT) of the temporal bone, CT-cisternogram, and combined transmastoid approach with middle fossa craniotomy in 2 patients.

MAIN OUTCOME MEASURES

Radiologic and operative diagnosis of congenital fallopian canal meningoceles.

RESULTS

Presentations included spontaneous cerebrospinal fluid (CSF) otorrhea and recurrent meningitis with intracranial hypertension. Postoperative complications included facial nerve palsy and persistent CSF leaks that necessitated ventriculoperitoneal shunt and lumbar drain placement.

CONCLUSION

Use of CT of the temporal bone in combination with CT-cisternogram may define sites of active CSF leak. Intraoperative use of fluorescein may assist identification of cranial base defects to lower rates of recurrence, and intraoperative use of cranial nerve monitoring can minimize the risk of nerve injury during repair.

Communication routes between intracranial spaces and inner ear: function, pathophysiologic importance and relations with inner ear diseases

OBJECTIVE

There exist 3 communication routes between the intracranial space and the inner ear, the vestibular aqueduct, the cochlear aqueduct, and the internal auditory canal. They possess a key role in inner ear pressure regulation and fluid homeostasis and are related to inner ear diseases.

REVIEW METHODS

Relevant literature was reviewed, and the current knowledge of the anatomy, physiologic importance, and relations to inner ear diseases were described. Pathologic communication routes such as semicircular canal dehiscence syndrome were highlighted as well.

CONCLUSION

Abnormalities in all 3 communication routes may predispose or be the cause of distinct inner ear pathologic condition and involved in other cochlear and vestibular syndromes, in which their role is not completely clear. The increasing knowledge of the underlying mechanisms encourages promising approaches for possible intervention in the future.

Spontaneous middle fossa encephalocele and cerebrospinal fluid leakage: diagnosis and management

OBJECTIVE

To evaluate the clinical presentation, operative findings, and surgical management of patients with spontaneous middle fossa encephalocele (SMFE) and cerebrospinal fluid (CSF) leakage repaired using a middle fossa craniotomy (MFC) approach.

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral center.

PATIENTS

Fifteen consecutive patients with 16 SMFE repaired using an MFC approach between January 1999 and April 2006 were included.

INTERVENTIONS

Patients were evaluated clinically and radiologically with computed tomography or magnetic resonance imaging. Encephaloceles were approached via MFC, and the cranial base was repaired in multilayered fashion using a variety of materials, including hydroxyapatite cement. Patients were followed clinically after discharge.

MAIN OUTCOME MEASURES

Postoperative complications, including CSF leak and the need for surgical revision, are evaluated. Patient factors, diagnostic testing, and operative findings are reviewed.

RESULTS

Diagnosis was made using clinical and radiologic evaluation in most patients. Beta2-transferrin testing was occasionally used in the diagnostic workup. Intraoperatively, multiple defects of the floor of the middle fossa were found in more than half of patients. Fifteen SMFE in 14 patients were successfully repaired via MFC alone. One patient required revision with a combined transmastoid/MFC approach due to recurrent CSF leakage. Hydroxyapatite cement was used for repair of the cranial base in 9 patients without complication.

CONCLUSION

An MFC approach can be used to repair SMFE with CSF leakage with a high level of success. Hydroxyapatite cement is a safe and useful adjunct to aid in reconstruction of the cranial base defects in cases of SMFE.

Facial Palsy and Fallopian Canal Expansion Associated With Idiopathic Intracranial Hypertension

OBJECTIVE

Describe neurotologic findings associated with idiopathic intracranial hypertension (IIH).

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral center.

PATIENTS

Case of IIH (>250 mm water) presenting with unilateral facial palsy and enlargement of the fallopian canal on computed tomography and magnetic resonance imaging.

INTERVENTION(S)

Oral acetazolamide, corticosteroids, and cerebrospinal fluid drainage.

MAIN OUTCOME MEASURE(S)

Intracranial pressure measurement, cranial nerve examination, audiometry, and symptom assessment.

RESULTS

Audiometry revealed asymmetric sensorineural hearing loss. Enlargement of the fallopian canal with cerebrospinal fluid was evident on imaging studies. Partial resolution of IIH symptoms was achieved.

CONCLUSION

IIH is an enigmatic disease entity. Increased intracranial pressure usually presents with headache and pulsatile tinnitus and is occasionally associated with cranial neuropathies. Abducens palsy is most common, producing diplopia. Cranial nerve involvement is often asymmetric, producing false localizing signs. Facial paralysis is an uncommon sequela of IIH. Treatment of IIH consists of reducing intracranial pressure. Corticosteroids are recommended for treatment of facial paralysis.

Diagnosis and Management of Otologic Cerebrospinal Fluid Leak

This article categorizes cerebrospinal fluid leaks as traumatic or nontraumatic in origin. It explains the physiology of the milieu of cerebrospinal fluid that surrounds the brain and spinal cord. It then discusses the detection, assessment, causes, clinical presentation, and management related to clinical pathologies.

Cerebrospinal Fluid Leaks of Temporal Bone Origin: Etiology and Management

BACKGROUND

Cerebrospinal fluid (CSF) leaks of the temporal bone region require surgical treatment as they pose life-threatening risks such as meningitis.

AIM

The aim of the study was to determine the surgical outcome depending on different operation techniques and grafts.

METHOD

We performed a retrospective review of 28 cases of CSF leaks, operated in our department from 1983 to 2002. After a mean follow-up of 8 years, patients were interviewed concerning otorrhea or rhinorrhea and meningitis. In this context, our management of CSF leaks is presented.

RESULTS

The CSF leak had arisen spontaneously (n = 3), traumatically (n = 6) or postoperatively (n = 19). The surgical CSF leak repairs were performed via a transmastoid (n = 13), a middle fossa (n = 11) or a combined (n = 4) approach. Surgical outcome was independent on the used graft. CSF leak could be sealed in 25 of 28 cases. Only 3 patients suffered from recurrences. Meningitis or other complications did not occur.

CONCLUSIONS

Comparing different techniques and grafts, there were no differences in the surgical outcome.

Hyrtl's fissure

Hyrtl's fissure is a transient anatomic landmark in the developing fetal petrous temporal bone and is usually closed by the normal progression of ossification in the 24th week of gestation. It occasionally persists into extrauterine life and has been reported as an unusual cause of a perilabyrinthine cerebrospinal fluid fistula. We present a case of a child presenting with bacterial meningitis because of a persistent Hyrtl's fissure. We have reviewed aspects of the fissure's developmental anatomy and previously published clinical cases. We have also explored the provenance of the eponym. We were unable to uncover evidence in support of the contention that Joseph Hyrtl was actually responsible for describing the structure commonly known as Hyrtl's fissure.

Arachnoid cyst of the fallopian canal: a surgical challenge

OBJECTIVE

Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are exceedingly rare, with only 6 reports appearing in the world literature. We report a seventh case that is unique in that it involves an arachnoid cyst of the fallopian canal and an associated facial nerve palsy.

STUDY DESIGN

Case report.

SETTING

International tertiary care referral center.

CONCLUSION

CSF otorhinorrhea associated with a facial nerve palsy may be indicative of an arachnoid cyst of the fallopian canal. These fistula are extremely rare. Surgical management involves sealing the fistula while preserving facial nerve function and is extremely challenging.

Spontaneous Cerebrospinal Fluid Leakage and Middle Ear Encephalocele in Seven Patients

Isolated cases of spontaneous cerebrospinal fluid (CSF) leakage with and without middle ear encephalocele have been reported. These leaks are usually accompanied by episodes of recurrent meningitis, hearing loss, or chronic headache. In this article, we report seven new cases of spontaneous CSF leakage. Six of these patients had conductive hearing loss and serous otitis media, and three had recurrent meningitis. Prior to a definitive diagnosis, six patients had received myringotomy tubes, which produced profuse clear otorrhea. Three patients had positive beta-2 transferrin assays. Computed tomography and magnetic resonance imaging confirmed a defect in the temporal bone tegmen. A combined transmastoid and middle fossa surgical approach with a three-layer closure was used to repair the tegmen defect. All patients had a lumbar drain placed prior to surgery. In addition to describing the seven new cases, we review the history of CSF leakage and discuss diagnostic methods, surgical findings, and our recommendations for management.

Spontaneous cerebrospinal fluid otorrhea from a tegmen defect: transmastoid repair with minicraniotomy

Spontaneous cerebrospinal fluid (CSF) otorrhea is a rare condition that presents in 2 clinical categories. In congenital labyrinthine malformations, it leads to bouts of meningitis in a hearing-impaired child. In the adult age group, a spontaneous CSF leak almost always results from a dural and bony defect in the tegmen area. Possible pathogenic mechanisms include progressive sagging and rupture of dura through a congenital tegmen dehiscence and progressive bone erosion by aberrant arachnoid granulations. These patients usually present with a middle ear effusion, resulting in clear discharge after myringotomy with tube insertion. Based on 4 patients with a CSF leak from a tegmen defect, this report reviews the clinical findings and diagnostic approach. The surgical management by a 5-layer closure using a transmastoid approach with minicraniotomy is outlined. This procedure offers a relatively simple and reliable method for repair without the inherent risks of a middle fossa craniotomy.

Recurrent meningitis in the pediatric patient--the otolaryngologist's role

OBJECTIVE

To assess the etiology of recurrent meningitis in the pediatric patient.

DESIGN

Retrospective case series and literature review.

SETTING

Tertiary-care pediatric hospital.

PATIENTS

Children (< 17-years-old) with recurrent meningitis, treated at Texas Children's Hospital (TCH) between 1984 and 1995.

RESULTS

A review of 463 cases of bacterial meningitis over an 11 year period revealed six children aged 3 months to 15 years with the diagnosis of recurrent meningitis. The patient's age, number of episodes of meningitis, diagnostic investigations performed and etiologies of recurrent meningitis were recorded. Fifteen episodes of meningitis were identified in these six patients; Streptococcus pneumoniae represented the bacteriology in 73% of the cases. Two patients were diagnosed with temporal bone abnormalities, two children with immunological deficiencies and no underlying etiology for the recurrent meningitis was identified in the remaining two patients. In this series, one-third of patients had an otolaryngologic etiology for their recurrent meningitis. These six patients, along with a review of the recent literature, will highlight the need for otolaryngological assessment and the importance of considering immunological investigations when managing recurrent meningitis in the pediatric patient.

CONCLUSION

We propose that children with recurrent meningitis of unknown etiology undergo: (1) an audiological evaluation; (2) a CT scan of the temporal bones, skull base and paranasal sinuses; and (3) an immunological evaluation.

Histopathology of spontaneous brain herniations into the middle ear

Two patients with spontaneous brain herniation into the middle ear have been operated on with a combined otoneurological approach. In case No. 1, two 2 x 3 mm arachnoid tissue herniations were found in the tegmen antri of the left ear. Six years later, a 8 x 9 mm mass consisting of prolapsed brain was removed from the right ear. The histological examination showed normal but disorganized nervous tissue. The surface consisted of middle ear mucosa or modified glial cells. More deeply numerous well preserved neurons and synapses were observed. In case No. 2, a 2 x 1 cm herniation was found in contact with the ossicles and the bony walls of the middle ear. The herniation consisted of partly degenerated nervous tissue which could explain the episode of temporal lobe seizure the patient experienced 8 years before surgery. In the world literature during the last 40 years, 29 cases of spontaneous or idiopathic brain herniation into the middle ear and mastoid have been reported. In 10, the herniations were multiple, as in our case No. 1. Case No. 1 is interesting also because the spontaneous brain herniation was bilateral.

Arachnoid granulation cerebrospinal fluid otorrhea

A case report and review of the temporal bone (TB) collection in the Department of Otolaryngology at SUNY Health Science Center in Syracuse demonstrated the occurrence of arachnoid granulations (AGs) in the posterior fossa surface of the TB and their role in cerebrospinal fluid (CSF) otorrhea. A large AG responsible for CSF otorrhea in a 64-year-old man was excised with soft tissue repair of the dural defect. Sixteen of 188 TBs (8.5%) in the collection contained 24 AGs ranging in size from 0.07 to 80.65 mm3. Nine AGs (37%) were small (less than 1 mm3) and did not demonstrate enlargement. Twelve (50%) were of intermediate size (2.50 to 9.32 mm3), and three (13%) were large (49.82 to 80.65 mm3). The intermediate and large AGs were associated with bone erosion and a high incidence of communication with a pneumatized mastoid complex (serous otitis media or meningitis). These findings suggest that AGs of sufficient size to produce bone erosion are the primary responsible lesions in adult-onset spontaneous CSF otorrhea.

Recurrent meningitis in children due to inner ear abnormalities

Recurrent meningitis in children is not only a potentially life threatening condition, but often involves the child in the trauma of repeated hospital admissions and multiple and invasive investigations to try and find an underlying cause. Symptoms and signs of CSF rhinorrhoea or otorrhoea are infrequent in these patients. Unilateral deafness may be difficult to diagnose in the young child. Full ENT examination may be normal. We report seven cases of children with recurrent meningitis in whom inner ear abnormalities were only indicated as the site of entry of infection by hypocycloidal tomography or high resolution CT scanning of the temporal bone. Subsequent tympanotomy confirmed the site of the CSF leak as the oval window in the majority of cases; packing the vestibule with muscle halted further attacks in these patients.

Tegmental and petromastoid defects in the temporal bone

Fifty temporal bones were examined using the temporal bone dissecting microscope. 34 per cent were found to have defects in the tegmen and petromastoid segments, resulting in communications between the cranial cavity and the middle ear cleft. However, no defects were found in the overlying dura. This may have an important bearing on the intracranial spread of infection from the middle ear cleft, even in the absence of any bony destruction due to chronic middle ear disease.

Perilymph fistulas in infants and children

During the years 1975 through 1981 we performed exploratory tympanotomies on 33 infants and children (44 ears) to verify the presumptive diagnosis of perilymph fistula (PLF). A PLF was identified at the round window, oval window, or both in 29 (66%) of the 44 ears explored. After surgery hearing was unchanged in 86%, improved in 5%, and worsened in 9% of the ears in which PLFs had been observed. Complaints of vertigo subsided in all children in whom a PLF was repaired. Preoperative factors determined to be highly suggestive of the presence of a PLF included the following: sudden onset of sensorineural hearing loss (SNHL), congenital deformities of the head, and abnormal findings on tomograms of the temporal bones, especially Mondini-like inner ear dysplasias. Middle ear abnormalities (primarily congenital) were observed in 20 of the 44 ears. Abnormal results of preoperative vestibular function studies, which included a fistula test, and sex were not consistently found to be associated with an observed PLF at tympanotomy.

Klippel-Feil syndrome with conductive deafness and histological findings of removed stapes

The Klippel-Feil syndrome is usually associated with sensorineural hearing impairment, but rarely is it associated with conductive or mixed deafness. A 22-year-old female presented with fusion of the cervical vertebrae, torticollis, scoliosis, pterygium colli, the Sprengel deformity with an omovertebral bone, concavity of the thorax and conductive hearing impairment of the right ear. Tympanotomy disclosed an atrophic long process of incus and a fixation of the stapes footplate, and stapedectomy was performed with immediate postoperative improvement of hearing. However, she developed a sudden hearing loss with dizziness soon after she had physical exercise on the 15th postoperative day, and revision surgery revealed a perilymph fistula of the oval window. Histological investigations of the removed stapes showed no specific osseous changes but hyperostosis of the posterior edge of the footplate. The literature is reviewed and the etiology of the conductive deafness and the perilymph fistula is discussed.

Recurrent meningitis, congenital anacusis and Mondini anomaly

Temporal bone polytomography should be performed in cases of recurrent meningitis, anacusis and vestibular areflexia. The finding of a Mondini-type anomaly is indicative of an oval window fistula. A further case is described, and scanning electron microscopic views of the defect in the stapedial footplate presented. Dysplasia of the otic capsule is considered to be the probable cause of this syndrome.

Diagnosis and treatment of spontaneous cerebrospinal fluid otorrhea

Two consecutively operated-on adult cases with spontaneous cerebrospinal fluid otorrhea were reviewed. Three meningoencephaloceles through tegmental defects were found. Each cele was peduculated through a small dural dehiscence partially obstructed by herniated brain. The otic capsule was normal in both cases. Bipolar cautery was used to reduce the size of the meningoencephalocele and to allow this tissue to assist in the closure of the defect. Conchal cartilage was placed through the tegmental defect to act as a self maintaining intracranial repair of the bony dehiscence. These cases and the literature suggest that fistulization of dura is more frequently the cause of spontaneous cerebrospinal fluid otorrhea in adults than is a defect in the otic capsule. Thus, direct surgical inspection of these areas is required.

Ben H. Senturia lecture. Leaking labyrinth lesions, deafness, tinnitus and dizziness

The remarkable integrity of the finely balanced membranous labyrinth is occasionally disrupted, resulting in fistulae of various types in a number of locations. Such leaking labyrinth lesions can be congenital origin, due to various types of malformations. They may be caused by destructive diseases such as syphilis, by many variants of acute and chronic otomastoiditis, and sequelae of otosclerosis surgery, and finally, as results of a variety of traumatic disruptions of labyrinthine integrity. Deafness dizziness, and tinnitus are frequent symptoms and sequelae may include meningitis and other intracranial complications. The clinical consideration of leaking labyrinth lesions must always be considered in otologic diagnoses.