Current Surgical Management in Middle Cranial Fossa Defects

Introduction: In the last decades, an increasing number of CSF leakage cases secondary to middle cranial fossa (MCF) defects have been reported. Multiple and varied surgical techniques to reconstruct this defect were described. Nevertheless, there is no evidence of the outcome superiority of one specific technique.

Objective: To review, analyze, and evaluate relevant surgical approaches described to repair MCF defects.

Methods: In this systematic review, we searched and included articles published until August 2021 without omitting earlier dates. The terms for searching title and abstract were “MCF; tegmen tympany; superior semicircular canal” and “CSF leak”; “MCF” and “reconstruction”; “MCF reconstruction” and “microscopic; endoscopic; transmastoid.” Articles were screened for duplicates and non-English language and relevance.

Results: Twenty-one relevant published articles were identified, including a total number of 381 patients. In 172 patients, an MCF approach (MCFA) was employed, whereas, for 150 patients, a transmastoid approach (TMA) was chosen; finally, 56 patients underwent a combination of both. A study reported that six patients operated through a minimally invasive endoscopic approach. In 69.5% of cases, a rigid reconstruction technique was preferred; a soft repair technique was used in the remaining cases (30.5%). The reconstruction technique involved multiple layers in the majority of the cases (89%). Four different types of repairing materials were identified: soft autologous, soft allografts, rigid autologous, and rigid allografts.

Discussion: TMA and MCFA represented the vast majority of surgical techniques employed for MCF defect repair. A few reports described the combination of both approaches, based on a potential unexpected multiple defect location. A single study provided new insights regarding an endoscopic-assisted minimal invasive repair. Two different reconstruction techniques have been described depending on the materials employed. The soft technique utilizes autologous materials (bone pate/dust, temporalis fascia-muscle, tensor fascia lata, aponeurotic galea, and fat grafts), or heterologous materials (fibrin glue, dura grafts, and sutures). The rigid technique employed also autologous materials (split calvaria and auricular conchal cartilage grafts) or allografts (titanium meshes, surgical cement, and hydroxyapatite discs). A sandwich technique involving a combination of materials has been described. The layer-material selection criteria among soft, rigid, and sandwich techniques are mainly guided by the defect dimension, where most large defects usually require a rigid or combined reconstruction. The current evidence available is mostly based on case reports or small case series. Therefore, extensive and controlled studies should be undertaken to have robust evidence to guide clinical practice.

Conclusion: Although there are many approaches and techniques to repair MCF defects, there is still a lack of robust evidence. Therefore, more exhaustive studies are required to guide the proper approach and technique to repair MCF defects.

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Artikel online veröffentlicht:
15. Februar 2022