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.
