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Outcome Objectives To (1) explore audiometric outcomes following use of a combined transmastoid/middle cranial fossa (TM-MCF) approach in the treatment of spontaneous cerebrospinal fluid (CSF) otorrhea and (2) determine the influence of dehiscence location and reconstructive methodology on audiometric outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults with spontaneous CSF otorrhea were reviewed from 2007 to 2016 if they underwent combined TM-MCF. Definitive audiometric evaluations were performed at least 3 months postoperatively. The primary outcomes measures were pre- to postoperative changes in pure-tone average (PTA) and air-bone gap (ABG). Two subset analyses were performed for audiometric outcomes comparisons: first, patients with skull base dehiscences anterior to the ossicular chain were compared with those with posterior dehiscences. Second, patients undergoing skull base resurfacing plus abdominal fat graft mastoid obliteration (AFGMO) were compared with those undergoing resurfacing alone. Results A total of 28 patients and 31 ears were reviewed. There was 1 recurrent leak (3.5%). The cohort demonstrated significant improvement in mean postoperative ABG ( P = .008) but not PTA. On subset analysis, ears with posterior dehiscences demonstrated significant improvements in PTA ( P = .03) and ABG ( P = .05), while ears with anterior dehiscences did not. In addition, ears undergoing resurfacing plus AFGMO achieved significant improvements on all parameters ( P = .01). Only 3 of 15 ears undergoing resurfacing plus AFGMO experienced worsened postoperative hearing. Conclusion Use of the combined TM-MCF approach for treating spontaneous CSF otorrhea achieved good audiometric outcomes. Patients with skull base dehiscences posterior to the ossicles and those undergoing skull base resurfacing plus AFGMO achieved the most favorable results.

Outcome Objectives To (1) identify unique features of patients who underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal for spontaneous cerebrospinal fluid (CSF) otorrhea and (2) explore outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults treated for spontaneous cerebrospinal fluid otorrhea from 2007 through 2015 were reviewed and stratified into 2 groups based on the surgery performed: (1) 11 patients underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal and (2) 26 patients underwent other procedures. Demographics, body mass index, revised cardiac risk index, Duke Activity Status Index scores, and anticoagulation use were documented. Audiologic data were gathered from pre- and postoperative visits. The primary outcome measure was leak recurrence. Complications were tabulated. Results Poor preoperative hearing was a relative indication for obliteration. Obliteration patients had higher body mass index (43.2 vs 34.9 kg/m2; P < .05), incidence of super-morbid obesity (45% vs 7.6%; P = .015), anticoagulation usage (36% vs 0%; P = .004), cardiac risk scores (1.2 vs 0.1 dB; P < .0004), and Duke Activity Status Index scores. There was 1 leak recurrence (9%). Major and minor complication rates were 9% and 36%, respectively. Mean follow-up was 30.8 ± 8.6 months. Conclusion Middle ear and mastoid obliteration with blind-sac closure of the external auditory canal is effective for treating spontaneous CSF otorrhea. The small cohort reviewed did not experience any major perioperative morbidity. The technique may be best suited for patients with poor hearing, the infirm, and those in whom craniotomy is contraindicated.

Objectives: (1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal fluid (CSF) otorrhea. (2) Augment perioperative counseling of patients with abnormally thin skull bases., Study Design: Case series with chart review., Setting: Tertiary center. Patients with spontaneous CSF otorrhea have thin skull bases. This is associated with obesity and/or idiopathic intracranial hypertension. The influence of skull base thinning on perioperative outcomes is unknown., Subjects and Methods: A retrospective review was conducted from 2004 to 2014. Forty-eight cases of spontaneous CSF otorrhea met the inclusion criteria of primary surgery by the senior authors: preoperative dedicated temporal bone computed tomography, absence of other leak etiologies, and follow-up >6 months. Patients were stratified into thin (<0.9 mm) and thick (>0.9 mm) groups based on computed tomography measures of their tegmen. Primary outcomes measures were as follows: postoperative meningitis, recurrent leak, second site leak (contralateral ear/anterior fossa), and permanent shunt placement. Hearing outcomes were not assessed in this study., Results: Thirty and 15 patients composed the thin and thick groups, respectively. Both the incidence (P < .0001) and the rate (P = .005) of adverse outcomes were significantly higher in the thin group. Only 2 patients in the thick group experienced an adverse outcome. Eleven patients underwent multiple procedures for spontaneous leaks. The recurrence rate was 14.5%. All but 1 recurrence occurred in the thin group., Conclusions: An abnormally thin tegmen was significantly associated with adverse perioperative outcomes in cases of spontaneous CSF otorrhea. A thick skull base and the presence of an encephalocele may be protective against recurrence. The effect of untreated intracranial hypertension on the results is unknown., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objective: To determine the prevalence of superior semicircular canal dehiscence (SCD) in patients with spontaneous cerebrospinal fluid (CSF) otorrhea., Study Design: Case series with chart review., Setting: Tertiary care referral center., Subjects and Methods: Patients included have undergone a middle fossa craniotomy for repair of spontaneous CSF otorrhea between January 2007 and December 2011. The main outcome measure is the presence or absence of SCD observed during spontaneous CSF leak repair. Computed tomography (CT) imaging was also reviewed to determine the diagnostic accuracy of this modality., Results: Thirty-three ears in 31 patients underwent surgical repair for spontaneous CSF otorrhea via a middle fossa craniotomy. The average age at the time of repair was 60.5 years, and 80.6% of patients were female. A dehiscence of the superior canal was observed in 15.2% of ears (16.1% of individuals). No significant difference in age, body mass index, or sex was noted between those patients with or without a superior canal dehiscence. For the diagnosis of SCD, coronal CT was 100% sensitive and 91.7% specific. The positive predictive value and negative predictive value of CT were 66.7% and 100%, respectively., Conclusion: The prevalence of superior semicircular canal dehiscence in ears with spontaneous otorrhea is 15.2%. This prevalence is greater than the 0.5% reported in a temporal bone study of ears not selected for CSF otorrhea.

Otologic disease in patients infected with HIV occurs frequently and usually represents rhinologic disease and associated eustachian tube dysfunction rather than manifestations of HIV infection. As in all patients, the decision to operate on an HIV-infected individual who would benefit from major otologic surgery is a balance between the risks of the procedure and the possible benefits to the patient. Many concerns regarding wound infection and healing have been raised. The objective of this study is to evaluate the outcome of otologic procedures in this population. The charts of 9 men and 4 women were reviewed. Seven patients (54%) met the Centers for Disease Control and Prevention criteria for AIDS. Patients with chronic otitis media (46%) underwent tympanomastoidectomies, and the cases of acute mastoiditis (31%) were managed with simple mastoidectomies. Other procedures included repair of cerebrospinal fluid leak (15%) and stapedectomy (8%). Two patients had early complications and died during their hospitalizations. Three patients had prolonged hospital courses requiring long-term antibiotics. These 5 patients underwent urgent procedures and were severely immunocompromised. Of the remaining 8 patients only 2 had AIDS, and all had an uncomplicated postoperative course. Six of these patients were followed up for more than 1 year, and only 2 developed subsequent otologic disease.

A 35-year-old man had a 5-year history of fluctuating hearing loss in his only hearing ear. History and diagnostic tests indicated a perilymph fistula, a diagnosis subsequently confirmed by exploration. Primary and secondary repairs temporarily ameliorated symptoms. A spinal fluid to middle ear fluid pathway was identified by radioactive tracer. A patent cochlear aqueduct indicated on computed tomography scan was found and repaired through a posterior cranial fossa approach. Hearing was preserved, remaining relatively stable during the 2-year follow-up period.