Preauricular Transglenoid Eustachian Tube Drill Out for Persistent Cerebrospinal Fluid Rhinorrhea

Background: Cerebrospinal fluid (CSF) rhinorrhea following lateral skull base surgery can be a challenging complication when traditional management fails. We present a novel preauricular, transglenoid approach to Eustachian tube (ET) obliteration in the case of a 56-year-old woman with a persistent leak following a translabyrinthine craniotomy. We describe the case in detail and provide operative images to outline the approach.

Surgical Technique: An incision was made in the temporal area along the preauricular crease, with extension superiorly for access to a temporoparietal fascia flap, if needed. Dissection was performed between the external auditory canal cartilage and the parotid fascia until the zygomatic arch and temporomandibular joint were exposed. To expose the medial glenoid fossa, the entire TM joint was mobilized forward by elevating between the periosteum and the bone. Drilling through the medial glenoid fossa, transecting the central bony ET, an undercut cavity was created between the two exposed ends of the ET. A constant flow of CSF was identified, from the proximal ET. The leak was stopped as calcium phosphate bone cement was extruded under pressure into the cavity forcing cement into both the proximal and distal bony ET. As it cured, it was locked into place by the undercut edges of the cavity. The surgical site was then closed in multiple layers over a closed suction drain.

Results: Our patient had previously failed a revision obliteration of the craniotomy site and ET, ventriculoperitoneal shunt placement and a transoral–transpalatal approach to ET closure. She has done well following the transglenoid approach, with no evidence of CSF leakage to date.

Conclusion: This approach has been previously described for the repair of carotid artery aneurysms at the skull base, but it is not for persistent CSF rhinorrhea. We believe that it is a safe and definitive method for ET obliteration when other measures have failed.