Retrospective Review of Tegmen Dehiscence Presentation and Repair Using a Combined Transmastoid and Middle Cranial Fossa Approach

Objective: Tegmen dehiscence is an uncommon and often underdiagnosed condition. It is associated with an increased risk of meningitis, intracranial abscess, cranial neuropathy, and seizure. Various surgical approaches for tegmen dehiscence repair have been documented, but the comparative efficacy of differing surgical techniques remains unclear. The presentation and repair using a combined transmastoid and middle cranial fossa approach for a series of cases is described and evaluated in this study.

Methods: A series of 15 cases of patients diagnosed with tegmen dehiscence was retrospectively reviewed. These patients were all treated with a combined transmastoid and middle cranial approach to surgical repair. Data on presentation, surgical technique, and outcome were collected and analyzed. Preoperative and postoperative audiogram results were also compared.

Results: The patient series was 67% women with a mean age of 51.3 years and an average BMI of 37.8. Although each patient's presentation varied, the most common symptoms were hearing loss, otorrhea, tinnitus, and ear fullness. A majority of patients had a history of cholesteatoma, infection, and/or prior surgery in the middle ear or mastoid area. All patients underwent a combined approach to multilayered surgical repair using a temporal bone graft and temporalis fascia. DuraGen, Tisseel glue, abdominal fat graft, Dura-Guard, and DuraSeal glue were also used in selected patients. Postoperative complications were minimal, with no serious unresolved consequences. One patient experienced recurrent CSF leak, and one developed a mastoid infection following revision surgery; both of these resolved with treatment. Two patients experienced worsened hearing, while seven had improved hearing following surgery. Overall, a 77% improvement was found between incidence of all examined preoperative and postoperative symptoms.

Conclusion: This case series demonstrates the variable presentation of tegmen dehiscence and points to diagnostic factors that should arouse suspicion. Surgical closure is necessary to prevent further infection and neurological sequelae. A combined approach through both the transmastoid and middle cranial fossa routes provides adequate exposure of the defects. A multilayered repair technique including a temporal bone graft is advocated to provide a strong and lasting closure of the dehiscent area.