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.

[Imaging evaluation of cerebrospinal fluid otorrhea associated with inner ear malformation in children].

Objective: To explore the imaging evaluation of cerebrospinal fluid (CSF) otorrhea associated with inner ear malformation (IEM) in children. Methods: The clinical data of 28 children with CSF otorrhea associated with IEM confirmed by surgical exploration in Beijing Children's Hospital, from Nov, 2016 to Jan, 2021, were analyzed retrospectively,including 16 boys and 12 girls, aged from 8-month to 15-year and 8-month old, with a median age of 4-year old. The shapes of stapes were observed during the exploration surgery, and the imaging features of temporal bone high resolution CT(HRCT) and inner ear MRI pre- and post-operation were analyzed. Results: In 28 children with CSF otorrhea, 89.3%(25/28) had stapes footplates defect during exploration. Preoperative CT showed indirect signs such as IEM, tympanic membrane bulging, soft tissue in the tympanum and mastoid cavity. IEM included four kinds: incomplete partition type I (IP-Ⅰ), common cavity (CC), incomplete partition type Ⅱ (IP-Ⅱ), and cochlear aplasia (CA); 100%(28/28) presented with vestibule dilation; 85.7%(24/28) with a defect in the lamina cribrosa of the internal auditory canal. The direct diagnostic sign of CSF otorrrhea could be seen in 73.9%(17/23) pre-operative MRI: two T2-weighted hyperintense signals between vestibule and middle ear cavity were connected by slightly lower or mixed intense T2-weighted signals, and obvious in the coronal-plane; 100%(23/23) hyperintense T2-weighted signals in the tympanum connected with those in the Eustachian tube.In post-operative CT, the soft tissues in the tympanum and mastoid cavity decreased or disappeared as early as one week. In post-operative MRI, the hyperintense T2-weighted signals of tympanum and mastoid decreased or disappeared in 3 days to 1 month,soft tissues tamponade with moderate intense T2-weighted signal were seen in the vestibule in 1-4 months. Conclusions: IP-Ⅰ, CC, IP-Ⅱ and CA with dilated vestibule can lead to CSF otorrhea. Combined with special medical history, T2-weighted signal of inner ear MRI can provide diagnostic basie for most children with IEM and CSF otorrhea.HRCT and MRI of inner ear can also be used to evaluate the effect of surgery.

Imaging evaluation of cerebrospinal fluid otorrhea associated with inner ear malformation in children / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the imaging evaluation of cerebrospinal fluid (CSF) otorrhea associated with inner ear malformation (IEM) in children. Methods: The clinical data of 28 children with CSF otorrhea associated with IEM confirmed by surgical exploration in Beijing Children's Hospital, from Nov, 2016 to Jan, 2021, were analyzed retrospectively,including 16 boys and 12 girls, aged from 8-month to 15-year and 8-month old, with a median age of 4-year old. The shapes of stapes were observed during the exploration surgery, and the imaging features of temporal bone high resolution CT(HRCT) and inner ear MRI pre- and post-operation were analyzed. Results: In 28 children with CSF otorrhea, 89.3%(25/28) had stapes footplates defect during exploration. Preoperative CT showed indirect signs such as IEM, tympanic membrane bulging, soft tissue in the tympanum and mastoid cavity. IEM included four kinds: incomplete partition type I (IP-Ⅰ), common cavity (CC), incomplete partition type Ⅱ (IP-Ⅱ), and cochlear aplasia (CA); 100%(28/28) presented with vestibule dilation; 85.7%(24/28) with a defect in the lamina cribrosa of the internal auditory canal. The direct diagnostic sign of CSF otorrrhea could be seen in 73.9%(17/23) pre-operative MRI: two T2-weighted hyperintense signals between vestibule and middle ear cavity were connected by slightly lower or mixed intense T2-weighted signals, and obvious in the coronal-plane; 100%(23/23) hyperintense T2-weighted signals in the tympanum connected with those in the Eustachian tube.In post-operative CT, the soft tissues in the tympanum and mastoid cavity decreased or disappeared as early as one week. In post-operative MRI, the hyperintense T2-weighted signals of tympanum and mastoid decreased or disappeared in 3 days to 1 month,soft tissues tamponade with moderate intense T2-weighted signal were seen in the vestibule in 1-4 months. Conclusions: IP-Ⅰ, CC, IP-Ⅱ and CA with dilated vestibule can lead to CSF otorrhea. Combined with special medical history, T2-weighted signal of inner ear MRI can provide diagnostic basie for most children with IEM and CSF otorrhea.HRCT and MRI of inner ear can also be used to evaluate the effect of surgery.

Treatment of tegmen dehiscence using a middle fossa approach and autologous temporalis fascia graft: Outcomes from a single center.

INTRODUCTION: Although bony defects of the tegmen surface are relatively common, the majority of dehiscences are asymptomatic. For those who experience symptoms, there is a wide spectrum of relatively benign manifestations such as hearing loss and otorrhea to potentially more serious but rare sequelae such as epilepsy and meningitis. Surgical management of tegmen dehiscences (TDs) can help prevent these symptoms. In this manuscript, we present one of the largest reported single team experiences of using a temporal craniotomy with middle cranial fossa approach and temporalis fascia graft in the treatment of tegmen defects. METHODS: We retrospectively reviewed every case of a TD surgically repaired by the same neurosurgeon/otolaryngologist team at Loyola University Medical Center from May 2015 to January 2022. In our chart review, we identified 44 patients with 48 cases of tegmen defect repair. We analyzed patient characteristics, operative details, and postoperative outcomes. RESULTS: 44 patients met inclusion criteria for the presence of TD (mean age 55 years, 55% male, and average body mass index 35.6). 89% of these patients had no clear etiology for the dehiscence. Commonly reported symptoms were hearing loss (89%) and CSF otorrhea (82%). The least reported presenting signs and symptoms were seizures (5%) and meningitis (2%). Most defects were repaired with both temporalis fascial and calvarial bone grafts (63%), while a minority were treated with temporalis fascia only (33%), temporalis fascia with muscle (2%), or fascia lata (2%). Every patient in our sample experienced resolution of CSF otorrhea after tegmen repair and 81% of the sample reported subjective hearing improvements after surgery. 6% of our sample had post-operative infections and 8% of patients underwent repeat unilateral surgery for a surgical complication. CONCLUSION: Craniotomy for middle fossa approach using autologous temporalis fascial grafts is a safe and effective method for the treatment of TD. These procedures should be performed by experienced and multidisciplinary teams.

[Surgical management of 27 cases with temporal bone cerebrospinal fluid leakage].

Objective:To study the clinical manifestations and surgical treatment of temporal bone cerebrospinal fluid leakage. Methods:The clinical data of twenty seven cases with temporal bone cerebrospinal fluid leakage were analyzed retrospectively. Different surgical procedures were adopted according to the location of the leak and the hearing status of the affected ear.If the leakage location was clear before surgery, direct repair was performed via mastoid path or middle cranial fossa path with or without mastoid abdominal fat packing.For patients with unclear leak, large lesion or intractable CEREBROspinal fluid leakage of temporal bone, subtotal petrosal resection and abdominal fat packing were performed.Subtotal temporal bone resection and abdominal fat packing were performed for patients with cochlear involvement. Results:In this study, cases of temporal bone CSF leakage including 13 cases of inner ear malformation; 5 cases secondary to head trauma or previous surgery,5 cases of idiopathic intracranial hypertension or meningocele, 2 cases of langerhans histiocytosis in the temporal bone and 2 cases of inner ear inflammation. High resolution CT （HRCT） of temporal bone showed bone defect of inner auditory canal with vestibular communication in 13 patients with inner ear malformation.The temporal bone HRCT of the remaining 14 patients showed bone defects in the middle cranial fossa or posterior cranial fossa, while MRI of the temporal bone showed meningeal continuity interruption with cerebrospinal fluid inflow into the temporal bone or meningoencephalocele in 12 patients. The 26 patients were followed up from 6 months to 6 years. 1 patient lost follow-up.Meningitis recurred in only 1 patient with inner ear malformation, and subtotal resection of rock bone plus abdominal fat packing was performed.Postoperative hearing was preserved or improved in 7 patients.None of the patients had serious complications, and only 1 patient developed HB Grade Ⅱ facial paralysis after vestibular obliteration, and the facial paralysis recovered within one week. Conclusion:Temporal bone cerebrospinal fluid leakage is relatively rare. Surgical intervention should be taken as early as possible when conservative treatment is failure. Preoperative HRCT and MRI examination are necessary for the localization of the leakage, and individualized surgical approaches can be adopted according to the location of the leakage and the features of the lesion.

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.

Audiometric Outcomes Following Transmastoid and Middle Cranial Fossa Approaches for Repair of Cerebrospinal Fluid Otorrhea.

OBJECTIVE: Describe audiometric outcomes following transmastoid and middle cranial fossa (MCF) approaches for repair of cerebrospinal fluid (CSF) otorhinorrhea. STUDY DESIGN: Retrospective case series. SETTING: Tertiary skull base referral center. PATIENTS: Adult patients presenting with CSF otorhinorrhea undergoing operative repair between January 2009 and July 2019. INTERVENTION: Transmastoid repair, MCF repair, or a combined approach. MAIN OUTCOME MEASURES: Primary outcome measures included preoperative and postoperative four-frequency pure-tone average (PTA), air-bone gap (ABG) and word recognition score. Secondary outcomes included success of repair, recurrence of CSF leak, and length of stay. RESULTS: Twenty-nine patients underwent 32 operations (mean age 52 yr, 75.9% female). Twenty (62.5%) patients underwent transmastoid repair, while 8 (25%) underwent an MCF approach. Patients had significant postoperative improvement in both PTA (34.8 dB preop vs. 24.5 dB postop, p = 0.003) and ABG (20.2 dB preop vs. 8.6 dB postop, p  = 0.0001). CSF leak recurred in 3 patients (9.4%) over 17-month follow-up. Compared to MCF or combined approaches, transmastoid repair was associated with greater improvement in PTA (15.6 vs. 3.0 dB, p = 0.001) and shorter length of stay (0.3 vs. 1.2 days, p = 0.005). On subset analysis, patients with spontaneous CSF leaks, a single skull base defect, or meningoencephaloceles demonstrated significant audiometric improvements. CONCLUSIONS: The transmastoid approach for repair of CSF otorhinorrhea is effective, safe, and can be done on an outpatient basis. Patients with spontaneous CSF leaks, a single skull base defect, and associated encephaloceles may have better audiometric outcomes.

Post-traumatic orbitorrhea: An underestimated life-threatening complication following anterior skull base fractures.

Orbitorrhea is defined as a leak of cerebrospinal fluid from a cranio-orbital fistula. It is usually related to anterior skull base trauma. Orbitorrhea is an exceptional and life-threatening condition which should be promptly managed. We herein report the case of a right post-traumatic orbitorrhea following anterior skull base trauma. Conservative treatment was initially attempted. At 6 weeks, recurrence was noted, and the patient underwent neurosurgical management. A few months later, a secondary upper lid retraction was diagnosed and treated by full-thickness skin graft with favourable outcome. To our knowledge, fewer than 30 cases have been previously reported. Ophthalmologists should be aware of this life-threatening condition which could be underestimated.

Fetal Bovine Collagen Grafts for Repair of Tegmen Defects and Encephaloceles Via Middle Cranial Fossa Approach.

To evaluate the use of commercially available allogenic dural graft materials made of fetal bovine collagen, we present an analysis of our case series with use of autologous and allogenic graft materials. Patients who underwent surgical repair of a tegmen tympani defect associated with ipsilateral conductive hearing loss and cerebrospinal fluid (CSF) otorrhea using a middle cranial fossa (MCF) approach from 2004 to 2018 at Loyola University Medical Center were included. Resolution of CSF otorrhea, audiologic outcomes, facial nerve preservation, and surgical complications was analyzed. Thirty-three patients with an average age of 55.3 years (range: 21-78, standard deviation [SD]: 12.9) and body mass index of 34.4 (range: 22-51, SD: 7.4) underwent an MCF repair of a tegmen and dural defect. All patients presented with CSF otorrhea and conductive hearing loss ipsilateral to the defect. Repairs were made with combinations of allograft and autograft in 17 cases, allograft only in 15 cases, and autograft only in 5 cases. Improvement in hearing was noted in 33 cases, and resolution of CSF otorrhea was noted in 36 cases; one patient required repeat surgery which resolved CSF otorrhea. Three patients had minor complications; all these were in the autograft group. The MCF approach coupled with the use of fetal bovine collagen grafts is a safe and viable method to repair tegmen tympani and associated dural defects with salutary outcomes and low morbidity.

A Novel Surgical Technique for the Management of Cerebrospinal Fluid Gusher Encountered During Cochlear Implantation.

: Cerebrospinal fluid (CSF) gusher encountered during cochlear implantation are most commonly encountered in the setting of an inner ear abnormality. Repair of the gusher is essential to prevent CSF egress postoperatively and to decrease the risk of meningitis. Various methods to repair a CSF gusher have been described, including tight packing of the cochleostomy with fascia, lumbar drainage, and Eustachian tube packing with ear canal overclosure. We describe a novel and simple technique using a fascia ring placed around the cochlear implantation electrode (Cochlear Corporation, CI522) as a means to treat CSF gusher. The fascia is slid down the electrode after insertion, allowing circumferential coverage of the defect. The following video will provide an overview of patients at risk for CSF gusher and demonstrate the technique described above.SDC video link: http://links.lww.com/MAO/B52.

Diagnosis and management of pediatric cerebrospinal fluid leakage secondary to inner ear malformations: A report of 13 cases.

OBJECTIVES: Inner ear malformations (IEM) with cerebrospinal fluid (CSF) leakage in children is a rare condition, nevertheless, it may lead to meningitis. Early diagnosis and treatment are crucial. The aims of the study were to summarize the clinical characteristic of pediatric CSF leakage secondary to IEM, and to recommend transcanal endoscopic ear surgery (TEES) as an effective surgical technique for the treatment of CSF leakage with IEM in children. METHODS: This was a retrospective study. Thirteen children and fourteen ear surgery were included. Demographics, detail history, laboratory data, Audio test, and imageological examination results were recorded. All the pediatric patients underwent TEES. RESULTS: Most (92.31%) of the children presented with a history of rhinorrhea. 69.23% (9/13) of the children had suffered from meningitis, and the other had presented with respiratory tract infections. The follow-up duration ranged from 0.75 years to 5.29 years. Transcanal endoscopic repair of CSF leakage secondary to IEM was the first surgery with a success rate of 92.86% (13 out of 14 cases). A fistula could be found in the stapes footplate in all pediatric patients. CONCLUSION: Even if there has been no history of meningitis, the diagnosis of CSF leakage in children suffering from unilateral rhinorrhea and recurrent respiratory tract infection is considered. Auditory brainstem response (ABR) and Temporal bone computed tomography (CT) examinations are suggested to identify IEM. The TEES procedure is recommended in our study as the first choice that repairs CSF leakage secondary to IEM.

Surgical Treatment for Cerebrospinal Fluid Leaks in Patients With Inner Ear Malformations.

OBJECTIVE: The aim of this study is to present our technique of surgical closure in a series of patients suffering from cerebrospinal fluid (CSF) leak due to inner ear malformations. STUDY DESIGN AND SETTING: We conducted a retrospective study in our tertiary care academic department of pediatric otolaryngology. PATIENTS: We did include all patients who presented a CSF leak or bacterial meningitis (one episode or recurrent) related to a malformation of the inner ear. INTERVENTION(S): Through a retro-auricular or endaural approach we performed a filling of the vestibule cavity with multiple fragments of cartilage with perichondrium introduced through the oval window, after stapedectomy until a near-complete sealing was obtained. After the surgery, all patients received a treatment with acetazolamide during 15 days. MAIN OUTCOME MEASURE(S): We did evaluate our technics with the recurrence of CSF leak. RESULTS: Thirteen patients, from 1 to 14, were operated with our technics. With a follow-up of 4.4 ±â€Š4.7 years, only one patient needed a second intervention. None had a novel episode of meningitis. We observed no complication. The leak was observed in the oval fossa in 11 cases. CONCLUSIONS: Our "minimally invasive" technique of vestibular obliteration with cartilage inserted through the oval window after stapedectomy did demonstrate its safety and reliability.

Minimally Invasive Repair of Tegmen Defects Through Keyhole Middle Fossa Approach to Reduce Hospitalization.

OBJECTIVE: The middle fossa craniotomy for tegmen defect repair provides wide access. This approach often requires temporal lobe manipulation, lumbar drain placement, and longer recovery. We describe a keyhole middle fossa approach with a simple titanium skull base repair that allows for wide access with no temporal lobe manipulation and does not require lumbar drain placement, which results in a dramatic reduction in hospital length of stay. METHODS: A retrospective review was performed on 14 consecutive patients with spontaneous cerebrospinal fluid (CSF) otorrhea. Each patient underwent a keyhole middle fossa approach followed by multilayer dural repair with titanium mesh "gull wing" skull base reconstruction. Postoperative measures included operative time, length of hospital stay, CSF leak recurrence, and surgical complications (seizures, hemorrhage, aphasia, infection). RESULTS: The average age of the patients was 60.7 ± 12.7 years old, and average body mass index was 32.8 ± 7.9 kg/m2. Nine of the patients were female. The average operative time was 103 ± 32.8 minutes. The average hospital length of stay was 1.4 days. There were no cases of postoperative CSF otorrhea, meningitis, aphasia, or seizures. There were no recurrences over a mean follow-up of 20.3 months (range: 5-48 months). CONCLUSIONS: A minimally invasive keyhole middle fossa approach with a multilayer dural reconstruction including titanium mesh "gull wing" skull base repair provides a quick, effective treatment for a broad spectrum of tegmen defects and meningoencephaloceles. This exposure and reconstruction technique do not require the use of a lumbar drain and result in minimal hospitalization.

Investigation of Skull-Based Cerebrospinal Fluid Leak Repair: A Single-Institution Comprehensive Study of 116 Cases Over 10 Years.

BACKGROUND: Cerebrospinal fluid (CSF) leaks have been historically difficult to diagnose and treat because their cause can widely vary. There are insufficient diagnostic predictors and no clinically accepted standards for their treatment. This large institutional study reports on the diagnosis, management, and outcomes of patients presenting with CSF leak over 10 years and aims to identify potential comorbidities and risk factors for primary and recurrent leaks. METHODS: Patients diagnosed with CSF leak from 2007 to 2017 were analyzed retrospectively. The data included medical history, body mass index, surgical treatment, and postoperative outcomes. RESULTS: A total of 116 cases were identified. The location of leaks was 91 CSF rhinorrhea and 28 CSF otorrhea (3 both). The average BMI for females was greater than that of males (P = 0.01). Causes of leak were 64 noniatrogenic, 47 iatrogenic, and 9 traumatic. A total of 108 patients underwent surgical treatment. Sixty-nine were treated by endoscopic approaches, 42 involved open approaches, and 83 involved the placement of a lumbar drain. Eighteen patients had a ventriculoperitoneal shunt and 6 had a lumbar-peritoneal shunt. A total of 78 patients (72.22%) had an associated encephalocele with the CSF leak. The average length of stay was 7.73 days (0.76). The average length of follow-up was 1.58 years (0.22). The primary repair rate was 80.17% (n = 93) and the overall repair outcome was 99.14% (n = 115). CONCLUSIONS: The overall CSF repair outcome was 99.14% over 10 years at a single institution. Despite this high percentage, CSF leaks continue to be a complex problem and require vigorous multidisciplinary work with close follow-up and use of multiple imaging strategies.

Our Experience in the Management of CSF Otorrhea: A Transmastoid Approach with Middle Ear Cavity Obliteration and a Middle Cranial Fossa Approach.

In this report, we present two cases of patients with cerebrospinal fluid (CSF) otorrhea who underwent surgical repair through either a transmastoid or middle cranial fossa approach. In our first case, a 34-year-old male after head trauma with conductive hearing loss and a House-Brackmann grade 2 facial palsy was found to have a soft tissue mass protruding through his right tympanic membrane. Radiological examination revealed a wide tegmen tympani defect. He underwent surgery via a transmastoid approach with repair of the defect and blind sac closure of the external auditory canal after middle ear cavity obliteration. Our second case involved a 50-year-old female who had developed chronic clear otorrhea following tympanostomy tube placement. Radiological evaluation revealed a tegmen tympani defect and CSF fistula. She underwent a middle cranial fossa approach in which a multilayer closure technique was performed. These two cases illustrate that the type of surgical approach for the CSF otorrhea repair depends on the location and size of the defect and hearing status. We recommend a multilayer closure to ensure proper resolution of the defect.

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.

Temporal bone meningoencephaloceles and cerebrospinal fluid leaks: experience in a tertiary care hospital.

OBJECTIVE: To recount experience with cerebrospinal fluid otorrhoea and temporal bone meningoencephalocele repair in a tertiary care hospital. METHOD: A retrospective review was conducted of 16 cerebrospinal fluid otorrhoea and meningoencephalic herniation patients managed surgically from 1991 to 2016. RESULTS: Aetiology was: congenital (n = 3), post-traumatic (n = 2), spontaneous (n = 1) or post-mastoidectomy (n = 10). Surgical repair was undertaken by combined middle cranial fossa and transmastoid approach in 3 patients, transmastoid approach in 2, oval window plugging in 1, and subtotal petrosectomy with middle-ear obliteration in 10. All patients had successful long-term outcomes, except one, who experienced recurrence after primary stage oval window plugging, but has been recurrence-free after second-stage subtotal petrosectomy with middle-ear obliteration. CONCLUSION: Dural injury or exposure in mastoidectomy may lead to cerebrospinal fluid otorrhoea or meningoencephalic herniation years later. Congenital, spontaneous and traumatic temporal bone defects may present similarly. Middle cranial fossa dural repair, transmastoid multilayer closure and subtotal petrosectomy with middle-ear obliteration were successful procedures. Subtotal petrosectomy with middle-ear obliteration offers advantages over middle cranial fossa dural repair alone; soft tissue closure is more robust and is preferred in situations where hearing preservation is not a priority.