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Encephaloceles and Cerebrospinal Fluid Leaks
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
6 sections · 95 slides
Overview and CSF physiology
- Definition of a cranial CSF leak
- Clinical importance of CSF leaks
- Anterior versus lateral skull base leaks
- Cerebrospinal fluid production and volume
- CSF circulation and absorption
- Normal and raised CSF opening pressure
- Mechanism of a high-pressure spontaneous leak
Causes of lateral skull base CSF leaks
- Classification of cranial CSF leaks
- Causes of lateral temporal bone CSF leaks
- Traumatic CSF leaks
- CSF leak after skull base surgery
- Epidemiology of spontaneous CSF leaks
- Obesity, sleep apnoea and intracranial hypertension
- Rising rate of spontaneous leak repair
- Other causes of high-pressure CSF leaks
- Congenital causes of normal-pressure leaks
- Inner ear malformations and stapes gusher
- Aberrant arachnoid granulations
- Tumour and infection causing normal-pressure leaks
Diagnosis
- Presentation after trauma or skull base surgery
- Presenting symptoms of spontaneous CSF leak
- Clear otorrhoea through a tympanostomy tube
- Tension pneumocephalus and meningitis
- Symptoms suggesting IIH or superior canal dehiscence
- Otoscopic findings
- Audiometric and nasopharyngeal assessment
- Encephalocele on examination
- Fundoscopy in suspected intracranial hypertension
- The Dandy maneuver as a provocation test
- Provocation testing with the Dandy maneuver
- Beta-2 transferrin as the confirmatory test
- When confirmatory testing is unnecessary
- Sampling options when the diagnosis is uncertain
- High-resolution CT of the temporal bone
- Sites to inspect on the CT
- Skull base dehiscence and superior canal dehiscence
- CT and MRI appearances of tegmen defects and encephalocele
- Magnetic resonance imaging
- MRI signs of idiopathic intracranial hypertension
- CT cisternography
Repair of spontaneous CSF leaks
- Indications for surgical repair
- Medical management of intracranial hypertension
- Choice of approach by defect location
- Defect position relative to the ossicles
- Single versus multiple bony defects
- Preoperative checks before a middle fossa approach
- The three described surgical approaches
- Goals of reconstruction
- Indications for the middle fossa approach
- Advantages and drawbacks of the middle fossa approach
- Middle fossa exposure
- Dural elevation and handling the encephalocele
- Dural repair
- Materials for bony reconstruction
- Multilayered repair using fascia and bone
- Sequence of the sandwich repair
- Resurfacing the floor in intracranial hypertension
- Lumbar drain use and closure
- Indications for the transmastoid approach
- Advantages and drawbacks of the transmastoid approach
- Transmastoid technique
- Intraoperative encephalocele in the epitympanum
- Rationale for the combined transmastoid-middle fossa approach
- Combined transmastoid and middle fossa exposure and repair
- Combined approach technique
Postoperative CSF leaks after skull base surgery
- Timing and presentation of postoperative leaks
- Prevention: translabyrinthine incision and closure
- Layered closure of the translabyrinthine wound
- Sealing routes of CSF egress in the translabyrinthine ear
- Prevention in the retrosigmoid approach
- Management of postoperative incisional CSF leak
- Lumbar drain management
- Postoperative CSF rhinorrhoea
- Eustachian tube obliteration
Post-traumatic leaks and summary
- Management of post-traumatic CSF leaks
- Conservative management outcomes
- Key messages: diagnosis
- Key messages: management
- References
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- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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