Spontaneous Cerebrospinal Fluid Leakage of Temporal Bone Origin: Selection of Surgical Approach

Introduction: Spontaneous cerebrospinal fluid (CSF) leaks of temporal bone origin are rare, often occult, and sometimes challenging to precisely localize and repair. Modern imaging modalities do not always demonstrate the size or location of the dural defect, and so the best approach for surgical repair can be difficult to determine.

Methods: A retrospective study was performed on 11 patients treated in a tertiary medical center over a 3-year period. Eight patients had spontaneous CSF leaks, of which four presented with meningitis and four with otorrhea. Three additional patients were found to have encephaloceles or CSF leaks during revision mastoid surgery for cholesteatoma.

Results: All but two patients received preoperative temporal bone CT; six also underwent MRI, one had CT cisternography, and one had radionuclide cisternography. All patients initially underwent a transmastoid surgical approach. Four patients also underwent a simultaneous transcranial approach because of anterior extension of the defect or a large meningocele. Surgical repair was successful in six of the eight patients with spontaneous leaks and in all three chronic ear patients with encephaloceles or CSF leaks. Both recurrences required intradural middle fossa repair.

Conclusions: An individualized approach should be taken for repair of temporal bone CSF leaks. In this series, most were successfully repaired in a single stage using a transmastoid or combined approach. The transmastoid approach provides information about the precise size and location of the dural defect. A primary transcranial approach is needed for defects that are multiple or located in the petrous apex, and in patients with a history of skull base irradiation.