Bilateral temporal bone encephaloceles after cranial irradiation. Case report

Successful surgical management of a complex temporal bone defect with brain contusion, meningocele, and CSF leak: A case report

INTRODUCTION

Brain tissue can herniate through skull base defects, resulting in a condition known as Meningoencephalocele; it is always a surgical disease with many approaches (transmastoid, middle cranial fossa, and combined approach).

CASE PRESENTATION

A 27-year-old male presented with right ear otorrhea, hearing loss, tinnitus, and headache. His medical history included a cranioplasty with a titanium mesh for repairing a skull fracture after head trauma and two episodes of meningitis with hospitalization. Physical examination revealed ear deformity and a pulsatile mass. Imaging studies confirmed a large tegmen tympani defect with meningocele and brain contusion. A transmastoid approach was used to repair the defect and address the CSF leak. Postoperatively, the patient's symptoms resolved, and hearing improved with no complications noted during follow-up.

DISCUSSION

This article highlights the complexity and challenges involved in managing such a case, given the accompanying complications and symptoms; and the effectiveness of a well-planned surgical approach.

CONCLUSION

Prompt diagnosis of CSF otorrhea is crucial. Clinical examination, endoscopy, and imaging are essential to identify the defect. The optimal surgical approach is determined by the defect's size, location, and the patient's condition, in conjunction with the surgeon's expertise.

An Uncommon Differential for Mass in the Middle Ear Cleft-Temporal Meningoencephalocele

Meningoencephalocoele (ME) of the temporal bone is otherwise known as brain fungus. It is a rare and potentially life-threatening condition. It occurs in cases of chronic otitis media either as a complication or iatrogenically induced following mastoid surgeries. It requires prompt surgical intervention. High-resolution Computer tomography of Temporal bone and Magnetic resonance imaging of the brain are needed to detect these cases. Surgery can be otological, neurosurgical, or combined. We discuss a case of Iatrogenic Temporal meningoencephalocele and its management along with a review of the literature.

The Role of Obesity in Iatrogenic Encephaloceles of the Temporal Bone

OBJECTIVE

Acquired encephaloceles of the temporal bone may be traumatic, spontaneous, or from chronic ear disease or previous surgery. Iatrogenic encephaloceles arise in the setting of previous mastoidectomy and traditionally involve both bony dehiscence and dural injury. We aim to classify and analyze the pathogenesis, clinical presentation, and treatment options for patients with iatrogenic tegmen defects and encephaloceles of the temporal bone.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary academic center.

PATIENTS

Subjects with iatrogenic tegmen defects and encephaloceles of the temporal bone were included.

INTERVENTION

Patient demographics, history, symptoms, radiographic data, intraoperative findings, management, follow-up, and outcomes were recorded.

OUTCOME MEASURES

Primary outcome measures included patient characteristics, time from primary otologic surgery to surgical repair, location of the defect, and management strategy including surgical approach, methods, and follow-up.

RESULTS

Iatrogenic tegmen injuries or encephaloceles were identified in 18 patients and divided into intentional or unintentional. The latter group presented immediately, early, or late, as determined by intraoperative identification or from delayed symptoms. Eleven patients presented late with previously unrecognized encephaloceles. Compared with patients presenting with incidentally noted tegmen dehiscence during revision mastoidectomy, a significant proportion of patients with late encephaloceles had BMI ≥30 kg/m (p = 0.03).

CONCLUSION

The majority of iatrogenic encephaloceles are unintentional, unrecognized, and may present many years after primary surgery. Similar to spontaneous encephaloceles of the temporal bone, obesity is associated with iatrogenic encephaloceles, although the rate of progression and timing is unclear. We recommend primary repair of any unintentional tegmen defect encountered during mastoid surgery, especially in obese patients.

The Prevalence of Superior Semicircular Canal Dehiscence in Patients With Mastoid Encephalocele or Cerebrospinal Fluid Otorrhea

OBJECTIVE

To evaluate the association between mastoid encephalocele or cerebrospinal fluid (CSF) otorrhea and concurrent superior semicircular canal dehiscence (SSCD).

STUDY DESIGN

Retrospective case-control study with chart and imaging review.

SETTING

University-affiliated tertiary referral center.

PATIENTS

A chart review was conducted of all patients greater than 18 years of age who had primary surgery for CSF otorrhea or encephalocele at our university-affiliated tertiary center from 2000 to 2016. Eighty-three patients matched inclusion criteria for case subjects, and 100 patients without CSF otorrhea or encephalocele were included for controls.

MAIN OUTCOME MEASURE

High-resolution computed tomography (CT) scans were reviewed to assess superior semicircular canal roof integrity. Student's t test was used to determine significance of continuous variables. Odds ratio (OR) and χ test was used to determine the association between SSCD and concurrent mastoid encephalocele or CSF otorrhea compared with the control population.

RESULTS

The mean age of the 83 case subjects was 54 years, and 73% were women. In patients with confirmed encephalocele and CSF otorrhea, the prevalence of SSCD was 35%, which was significantly greater than controls (2%) (OR = 26.1, p < 0.001). In patients with only CSF otorrhea, 21% had concurrent SSCD (OR = 10.3, p = 0.001). In patients with SSCD, 46% had bilateral canal dehiscence.

CONCLUSIONS

This is the largest study to evaluate the prevalence of SSCD in patients with concurrent mastoid encephalocele. This study showed a significant association between SSCD and the presence of both mastoid encephalocele and CSF otorrhea. This data suggests that surgeons should have a high suspicion for SSCD in patients presenting with encephalocele or CSF otorrhea.

Posttraumatic Temporal Bone Meningocele Presenting as a Cystic Mass in the External Auditory Canal

INTRODUCTION

Temporal bone meningoencephalic herniation may occur in head trauma. It is a rare condition with potentially dangerous complications. Several different routes for temporal bone meningoencephalocele have been proposed.

CLINICAL REPORT

An11-year-old boy with history of head trauma initially presented with a 9-months history of progressive right-sided hearing loss and facial weakness. The other complaint was formation of a cystic mass in the right external auditory canal. The patient underwent surgery via a mini middle cranial fossa craniotomy associated with a transmastoid approach.

CONCLUSION

Although presenting symptoms can be subtle, early suspicion and confirmatory imaging aid in establishing the diagnosis. The combination of computed tomography and magnetic resonance imaging will help in proper preoperative diagnosis. The operation includes transmastoid, middle cranial fossa repair, or combination of both. The multilayer closure of bony defect is very important to avoid cerebrospinal fluid leak. Clinical manifestations, diagnosis, and surgical approaches for posttraumatic meningoencephaloceles arising in the head and neck region are briefly discussed.

Single Operation to Repair Multifocal Cerebrospinal Fluid Fistulae Following Gunshot Wound: A Case Report

Introduction Traumatic cerebrospinal fluid (CSF) fistulae can be a challenging neurosurgical disease, often requiring complicated surgical intervention. Case Presentation A 54-year-old man presented with a gunshot wound to the head with complex injury to the skull base and significant CSF leakage from multiple sites. A single surgery was performed using a combined Neurosurgery, Neurotology, and Rhinology team, which was successful in repairing the multiple skull base defects and preventing further CSF leak. Discussion Trauma to the skull base is a common inciting factor for the development of CSF fistulae. Endoscopic approaches are often preferred for repairing these defects, but craniotomy remains a viable option that may be required in more complex cases. A combined approach has not been described previously, but was successful for this severe multifocal defect. Conclusion A multidisciplinary approach allowed for a combined intervention that addressed both the anterior and middle fossae fistulae simultaneously. This limited the potential infectious complications of continued CSF leak and allowed for early rehabilitation.

Meningoencephalocoele in a mastoid cavity: a case report and review of literature

A young adult male presented to us with a discharging mastoid cavity. Clinical and radiological examination revealed cholesteatoma recidivism along with a meningoencephalocoele (ME) which was managed successfully. Two year follow-up revealed no recurrence of the pathology.

Tegmen tympani defect and brain herniation secondary to mastoid surgery: case presentation

Brain herniation into the middle ear is very rarely seen. In addition to reasons like congenital factors, trauma, and infection, tegmen defect may develop as a result of iatrogenic events secondary to chronic otitis media surgery with or without cholesteatoma. Since it may cause life-threatening complications, patients must be evaluated and monitored for tegmen defect. In this paper, diagnosis and treatment of a brain herniation case due to iatrogenic tegmen defect were described along with relevant literature.

Combined mastoid/middle cranial fossa repair of temporal bone encephalocele

Temporal bone encephalocele (TBE) has become less common as the incidence of chronic mastoid infection and surgery for this condition has decreased. Due to its declining incidence, the diagnosis of TBE may be delayed and result in the development of serious complications such as cerebrospinal fluid leak, meningitis, epidural or subdural abscess. Six cases of large (>1 cm) TBE of diverse etiology are described. Two patients had suffered previous temporal bone fractures, two had had prior mastoidectomy, and two patients had long-standing chronic mastoiditis. Two patients had undergone prior unsuccessful transmastoid repair. All patients underwent successful tegmen-dural repair with autogenous fascia, bone, and/or cartilage, primarily via a combined mastoid-middle fossa approach. Accurate dural closure and support of intacranial contents are imperative to prevent recurrence. We find that permanent repair can best be performed with a combined mastoid middle cranial fassa approach.

[Atypical etiology of rhinorrhea: spontaneous bilateral temporal encephalocele]

Spontaneous herniation of brain parenchyma through a dural and osseous defect in the temporal bone is a rare entity and a bilateral form is even more infrequent. It usually presents as an intermittent but persistent otorrhea. Manifestation as nose cerebrospinal fluid (CSF) leak is very uncommon. Our objective is presenting this unusual case report of a spontaneous bilateral encephalocele with a bilateral tegmen tympani defect.

The Role of the Middle Fossa approach in the Management of Traumatic Facial Paralysis

There are several controversial aspects to the management of traumatic facial paralysis. One of these involves the precise nature of surgical intervention once the decision to operate has been made. Between June 1, 1984, and June 30, 1993, we surgically treated 220 cases of traumatic facial paralysis with good cochlear reserve by decompressing the tympanic and mastoid segments via a transmastoid approach followed by decompression of the geniculate ganglion and the distal half of the labyrinthine segment via a middle fossa approach. We discuss the results of surgery via the middle fossa approach, and we review the literature.