ICP, BMI, surgical repair, and CSF diversion in patients presenting with spontaneous CSF otorrhea.

OBJECTIVE: To assess intracranial pressure (ICP), body mass index (BMI), surgical repair, and cerebrospinal fluid (CSF) diversion in patients presenting with spontaneous CSF otorrhea. STUDY DESIGN: Retrospective series review. SETTING: Tertiary referral center. PATIENTS: Thirty-two patients were treated surgically from 2004 to 2013 for spontaneous CSF otorrhea by the principal investigators. Patients with a history of chronic ear disease and cholesteatoma, previous mastoid surgery, head trauma, or iatrogenic injury were excluded. Average age was 56 years. Twenty-two patients (69%) were female. INTERVENTION(S): Middle fossa repair, transmastoid repair, lumbar puncture, V-P shunt, L-P shunt, and magnetic resonance imaging. MAIN OUTCOME MEASURE(S): Patients underwent middle fossa or transmastoid repair of tegmen defects. Intracranial pressures were determined with lumbar puncture at time of surgical repair or shortly after surgery. CSF diversion procedures were performed in patients who were found to have elevated ICP, which was not controlled medically, presented with recurrent leak or had ICP of 25 cm or greater of H2O. Preoperative BMI was calculated. RESULTS: Thirty-two patients underwent 37 operations. Average BMI was 35.0 kg/m2 (median, 34.7; range, 18.7-53.2 kg/m2). There were 21 repairs on the left and 16 on the right. The majority underwent a middle fossa craniotomy for repair (27/32). Two patients had bilateral repairs. Three patients (8%) underwent revision surgery, of which, 2 had untreated intracranial hypertension (ICP 24.5 and 24 cm H2O). ICP measurements were available for 29 patients. The mean ICP was 23.4 cm H2O (median, 24; range, 13-36 cm H20). Twenty-two patients (69%) had ICP of 20 cm or greater of H20; of those, 13 had an ICP of 25 cm or greater of H20. Seventeen patients (53%) underwent CSF diversion procedures. CONCLUSION: Our findings of elevated ICP and BMI in patients presenting with spontaneous CSF otorrhea are consistent with previous reports in the literature. The percentage of patients that underwent CSF diversion procedures was high at 53% and represents an aggressive stance in managing elevated ICP in a population that may be at risk for subsequent leaks.

Choroid plexus papilloma presenting with cerebrospinal fluid rhinorrhea and otorrhea: case report.

A 52-year-old woman presented with right rhinorrhea and right otorrhea manifesting as aural fullness for 2 years caused by a choroid plexus papilloma in the right cerebellomedullary cistern. Computed tomography and magnetic resonance imaging revealed a well defined lobulated mass at the foramen of Luschka, which extended towards the right cerebellomedullary cistern with slight dilation of the ventricular systems. The tumor was totally resected via a right lateral suboccipital approach. Histological examination revealed a choroid plexus papilloma. Postoperative course was uneventful, just after the operation rhinorrhea ceased completely, and hearing of the right ear dramatically improved. Choroid plexus papillomas rarely cause cerebrospinal fluid (CSF) rhinorrhea. Total removal of the tumor resulted in the cessation of CSF leaks.

Stereoscopic virtual reality presurgical planning for cerebrospinal otorrhea.

We present a complicated case of spontaneous cerebrospinal otorrhea, which had not been cured despite undergoing 5 surgical interventions in the past. The disability to identify the location of the fistula was the main crux of the past failures. On this occasion, stereoscopic virtual reality presurgical planning was applied to identify the exact location of the fistula and a surgical simulation was performed, and was later confirmed during the actual operation. Interactive manipulation in a stereoscopic virtual environment makes the decision making process easier in the treatment of cerebrospinal otorrhea.

Perioperative continuous cerebrospinal fluid pressure monitoring in patients with spontaneous cerebrospinal fluid leaks: presentation of a novel technique.

BACKGROUND: A few studies have used direct measurements of cerebral spinal fluid pressure (CSFP) using either lumbar punctures or pressure transducers to evaluate CSFP elevations as a potential etiology in patients with spontaneous CSF leaks. Limitations of these techniques include positional variation, inadequate duration of measurement, and insufficient analysis of waveforms. We propose a novel technique for more accurate measurement of CSFP in patients with spontaneous CSF leaks. METHODS: Patients with spontaneous CSF rhinorrhea had a lumbar catheter placed for 24-hour CSFP recording before and 72 hours after their endoscopic surgical repair. Heart rate, electrocardiogram, respirations, and oxygen saturation are recorded in addition to CSFP. Mean CSFP as well as the pulse waveform amplitude were calculated. RESULTS: Twelve patients with spontaneous CSF rhinorrhea underwent continuous CSFP monitoring. Seven patients had elevations in their CSFP of >25 cm H(2)O for at least 4% of their recording time during their continuous monitoring. Nine patients had significant oxygen desaturations associated with elevated CSFP. Pulse waveform amplitudes could average 20 cm H(2)O over several minutes in patients with mean CSFP of <10 cm H(2)O. CONCLUSION: Perioperative CSFP monitoring provides continuous data including mean and transient elevations in CSFP that can be correlated to other measurements such as oxygen saturation. This data may more accurately identify those CSF leak patients with elevated CSFP as well as correlate these elevations to prognostic clinical information that may improve treatment and outcome after their surgical repair.

Current imaging of cerebrospinal fluid leaks / Imágenes médicas actuales de pérdidas de fluido cerebroespinal

A CSF leak results from a defect in the dura and skull base. Due to the risk of potentially devastating central nervous system infection, it is an important entity. Timely diagnosis of CSF leaks is crucial. Laboratory testing of nasal or aural fluid drainage for the presence of the protein Beta(β)-2 transferrin plays a key role in establishing the presence of a CSF leak. Such assays are not always available, making imaging pivotal in the diagnosis of this entity. The development of minimally invasive endoscopic repair further underscores the importance of imaging as precise anatomic localization is important for repair. In this article, we review the literature and make suggestions for the appropriate radiological investigation ofpatients with suspected CSF leaks.

Las pérdidas de fluido cerebroespinal (FCE) son el resultado de un defecto en la dura y la base craneal. Debido a que tales pérdidas presentan el riesgo de infecciones capaces de devastar potencialmente el sistema nervioso central, las mismas constituyen una entidad importante. El diagnóstico a tiempo de pérdidas del FCE es crucial. Las pruebas de laboratorio realizadas al drenaje del fluido de la nariz y los oídos a fin de detectar la proteína Beta (β) 2 transferrina, desempeñan un papel clave a la hora de determinar la presencia de pérdida de FCE. Estos ensayos no se hallan siempre a disposición, con lo cual la imagen médica se hace fundamental para el diagnóstico de esta entidad. El desarrollo de reparaciones endoscópicas mínimamente invasivas subraya aún más la importancia de la imagen médica, por cuanto se requiere una localización anatómica precisa para realizar la reparación. En el presente artículo, se revisa la literatura y se hacen sugerencias a fin de lograr una investigación radiológica adecuada de los pacientes con sospecha de pérdida de FCE.

Current imaging of cerebrospinal fluid leaks.

A CSF leak results from a defect in the dura and skull base. Due to the risk of potentially devastating central nervous system infection, it is an important entity. Timely diagnosis of CSF leaks is crucial. Laboratory testing of nasal or aural fluid drainage for the presence of the protein Beta (beta)-2 transferrin plays a key role in establishing the presence of a CSF leak. Such assays are not always available, making imaging pivotal in the diagnosis of this entity. The development of minimally invasive endoscopic repair further underscores the importance of imaging as precise anatomic localization is important for repair In this article, we review the literature and make suggestions for the appropriate radiological investigation of patients with suspected CSF leaks.

Spontaneous cerebrospinal fluid otorrhoea presenting as otitis externa.

A case of spontaneous cerebrospinal fluid (CSF) otorrhoea in a 59-year-old lady is reported. The patient was initially diagnosed and treated for chronic otitis externa. Following the referral by her GP, it was found that her symptom of otorrhoea was secondary to cerebrospinal fluid leak with middle ear encephalocoele. The CSF leak was repaired using a transmastoid approach with fascia, bone paté and fibrin glue. In this paper, we describe an unusual case of spontaneous CSF otorrhoea presenting as otitis externa. We review the pathophysiology of spontaneous CSF otorrhoea, and discuss the pitfalls in the diagnosis of CSF otorrhoea.

Spontaneous resolution of syringomyelia and Chiari malformation Type I in a patient with cerebrospinal fluid otorrhea. Case report.

The spontaneous resolution of syringomyelia in the setting of a Chiari malformation Type I (CM-I) has been reported infrequently. Several theories about the pathogenesis and spontaneous resolution of syringomyelia associated with CM-I have been proposed. The authors present the case of a patient with spontaneous resolution of a CM-I and syringomyelia coinciding with the development of cerebrospinal fluid (CSF) otorrhea. Although cases of spontaneous resolution of syringomyelia have been reported, this is the first reported case of spontaneous resolution of syringomyelia and a CM-I associated with the simultaneous development of CSF otorrhea.

Adult spontaneous CSF otorrhea: correlation with radiographic empty sella.

OBJECTIVE: To determine the prevalence of radiographic empty sella in patients with spontaneous cerebrospinal fluid (CSF) otorrhea. STUDY DESIGN AND SETTING: Retrospective case series of adult patients with CSF otorhinorrhea at an academic tertiary medical center. Patients with history of skull base surgery, trauma, tumor, or chronic ear disease were excluded. Available imaging studies were reviewed with attention to the sella turcica. RESULTS: Eight patients were diagnosed with spontaneous CSF otorrhea. Five of seven patients with adequate imaging studies (71%) had a radiographic empty sella. Seven of eight patients were clinically obese, with a body mass index BMI>30 kg/m2. CONCLUSIONS: Empty sella is a common radiologic finding in patients with spontaneous CSF otorrhea. This supports the theory that increased intracranial pressure contributes to development of spontaneous CSF otorrhea. SIGNIFICANCE: Radiographic empty sella predicts elevated intracranial pressure, which may require further evaluation and treatment in patients with spontaneous CSF otorrhea. EBM RATING: C-4.

Epidural blood patch at C2: diagnosis and treatment of spontaneous intracranial hypotension.

Spontaneous intracranial hypotension in a 37-year-old man with intractable headaches was diagnosed on MR imaging. A generous CSF leak was identified at C2 on CT myelography. Successful treatment was performed with CT-guided blood patch at the leakage site after the patient had failed 2 lumbar blood patches. Imaging-guided precise placement of the blood patch is safe and recommended when a lumbar blood patch away from the leakage site could be ineffective.

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.

[Management of cerebrospinal fluid fistulae: physiopathology, imaging and treatment]. / Stratégie d'exploration d'une brèche ostéoméningée.

Cerebrospinal fluid (CSF) fistulae can produce leakage through a defect in the bony skull and meninges into the contiguous air-filled cavities at the base of the skull. The major risk is central nervous system infection. When abundant clear rhinorrhea or otorrhea is present, the diagnosis is obvious and imaging is used to localize the fistula. Computed tomography (CT) with millimetric slices and magnetic resonance imaging (MRI) are the most effective diagnostic tools. CT cisternography, an invasive procedure, should only be used when the diagnosis remains uncertain following CT scan and MRI. When CSF leakage is sparse or intermittent, the diagnosis can be made by measuring beta-2 transferrine in the escaping fluid. CT scan followed by MRI are also useful for making the diagnosis and locating the fistula when exterior leakage is absent. CT scan alone is effective for assessing isolated otorrhea. If the diagnosis remains uncertain after all these studies have been used, the patient should be closely followed clinically and isotopic study or surgery should be considered.

[Perilymphatic effusion as a complication of otosclerosis]. / Geyser lors de la chirurgie de l'otospongiose.

INTRODUCTION: Stapes gusher means the leakage of perilymphatic liquid when opening the perilymphatic cistern. The perilymphatic liquid with a high pressure gushes with a great flow out of the cistern when the stapedotomy is executed. Otosclerosis surgery sometime brings to light abnormal contact between the inner ear and the sub-arachnoidian spaces in patients who didn't presented ear malformations. It's a very rare event (1/1000) which is different from a much more common and more moderate form of perilymphatic liquids high pressure (1/200). About 4 clinical observations, we compared our experience with other authors in specialist reviews. PURPOSE OF THE STUDY: About four observations, we confronted our experience with that of the literature. MATERIAL AND METHODS: Retrospective study between 1971 and 1998. It was about 3 males and 1 female, without antecedent except one of them who had been operated 5 years before for the opposite ear without gusher but without good audiometric result. They presented a conductive deafness with no answer of the stapedial reflex. We had 4 geysers during the platinotomia which were sealed with some connective tissue. RESULTS: Two patients had a post operative complete sensory hearing loss, one, a sensitive decline of the conduction thresholds (average 50 dB), the last one kept his bone conduction level with a mild sensory hearing loss. The most recent case had a scanner preoperatively which had not shown abnormality except for the focus of otosclerosis. DISCUSSION: Perilymphatic gusher is an unpredictable event that can not be diagnosed before the surgery, nether with clinical facts nor radiological elements. This involves serious consequences concerning not only the continuation of the surgical operation and the prognostic of the hearing but also concerning the danger of secondary meningeal infections. The best way to proceed in case of favourable cases consists in fitting the ossicular prothesis into the stapedotomy, when it's not to wide. Pieces of muscle can be used in some cases, taped on with biologic glu. Various techniques are used to lower the pression of the cerebrospinal liquid: hypertonic solutes, diuretic drugs, lumbar diversion. In all cases, it is necessary to start a wide spectrum antibiotic treatment and a vaccination against pneumococcis. CONCLUSION: The surgeon has to know all the option of the treatment when confronted with this situation in order to try to avoid tricky defect of the inner ear.

[Criteria for assessing functional results in middle ear surgery]. / Criterios para valoración de resultados funcionales en la cirugía de oído medio.

INTRODUCTION AND OBJECTIVES: Comparison of reports of the functional results of middle-ear surgery is difficult because there are no standardized criteria, such as; auditory activity, histology, evaluation of functional results, follow-up period, etc. Moreover, surgeons and patients often disagree over the results obtained. The functional results obtained in 246 middle-ear operations performed in our department for postotorrhea sequelae were analyzed. MATERIAL AND METHOD: Using the SMYTH and PATTERSON criteria, benefits were analyzed in 246 patients for whom functional results were available. RESULTS: Benefits were analyzed by type of surgery, type of ossiculoplasty, presence or absence of stapedial superstructure, and subjective patient assessment. DISCUSSION AND CONCLUSIONS: Results were analyzed as surgical evaluation of functional outcome in relation to subjective patient assessment. Guidelines for standardizing criteria for the functional evaluation of middle-ear surgery are proposed.

Spontaneous cerebrospinal fluid otorrhea from defects of the temporal bone: a rare entity?

Cerebrospinal fluid (CSF) otorrhea is usually associated with a history of trauma or previous surgery. Spontaneous CSF otorrhea is uncommon. When such spontaneous CSF leakage occurs, it may be associated with dural herniation, with the production of conductive hearing loss from impingement on the ossicles. This type of leakage has characteristic findings which, if recognized, can lead to earlier diagnosis and avoidance of complications. A review of the world literature revealed 44 reported cases. This report presents the authors' experience with 12 patients with spontaneous CSF leakage from temporal bone defects. This entity may be more prevalent than is reported. The differential diagnosis and management of CSF otorrhea (secondary to temporal bone defects) are discussed and representative cases are presented.

Temporal bone fractures.

The diagnosis and monitoring of patients presenting to an emergency department with blunt temporal bone fracture and complications requiring acute management were reviewed for a four-month period. Of 104 trauma patients with closed head injury, 15 patients were diagnosed with temporal bone fracture, 12 of whom survived their injuries. Four patients developed cerebrospinal fluid (CSF) otorrhea and two patients developed facial nerve paralysis; all patients had resolution of complications with conservative management. Significant shortcomings in the initial evaluation and monitoring of patients with temporal bone fracture were identified. Specific and thorough facial nerve examinations were not initially conducted on temporal bone fracture patients and subsequent inpatient monitoring for facial nerve paralysis and CSF otorrhea was incomplete. The outcome of temporal bone fracture is discussed. This article reminds the emergency physician of the importance of initial diagnosis and documentation of temporal bone fractures.