Clinical Outcomes of Surgical and Pharmacological Treatment of Spontaneous Cerebrospinal Fluid Leaks to the Temporal Bone

Background: Surgical repairs of spontaneous CSF leaks to the temporal bone include middle cranial fossa (MCF), transtemporal, and combined approaches. Data on postoperative outcomes based on the surgical approach and preoperative imaging findings is limited. Acetazolamide has been found to reduce intracranial pressure (ICP), which makes it a theoretical adjunct therapy in treating CSF leaks when elevated ICP is suspected. However, there is a lack of evidence supporting using Acetazolamide as an adjunctive therapy for spontaneous CSF otorrhea. The objective of this study is to determine if a specific surgical approach, a surgical approach interacting with preoperative imaging findings, or the use of Acetazolamide reduces post-operative complications.

Methods: Electronic medical record query of two neurotologists' patients at an urban, tertiary medical center found 151 patients with a documented CSF leak between January 2008 and December 2019. Patients with previous head injury, cranial neoplasm, craniotomy, or otologic surgery other than tympanostomy placement were excluded, resulting in a remaining 119 patients who were defined as having spontaneous CSF leaks. Information on presenting symptoms, perioperative findings, surgical and postoperative management was collected. Fisher Exact tests were performed for binary outcomes. Simple logistic regression and multilogistic regression with interaction were also performed for binary outcomes.

Results: Sixty-two, 21, and 16 patients underwent MCF, transtemporal, and combined approaches for CSF leak repair, respectively. Nineteen patients were prescribed and adhered to post-operation Acetazolamide treatment. The average time between surgery and last follow-up was 15 months. The probability of ipsilateral otorrhea, rhinorrhea, aural fullness, headache, tinnitus, vertigo, hearing impairment, and otitis media resolution was the same for the 3 surgical approach groups. The probability of these symptoms resolving was also the same for the patients prescribed and not prescribed Acetazolamide. The probability of having a repeat ipsilateral CSF leak repair or ventriculoperitoneal shunt placement was the same for the three surgical approach groups. The probability of having a repeat ipsilateral CSF leak repair or ventriculoperitoneal shunt placement was the same for patients prescribed and not prescribed Acetazolamide. Magnetic resonance imaging and computed tomography findings of tegmen tympani defects, tegmen mastoideum defects, tympanic cavity opacification, and mastoid air cell opacification with an interaction with surgical approach did not have a statistically significant effect on ipsilateral leak recurrence or persistence of presenting symptoms. Graft material used for surgical repair included dural substitutes, bone cement, bone grafts, temporalis fascia, and rotational flaps of the temporalis muscle. Graft material with an interaction with surgical approach did not have a statistically significant effect on ipsilateral leak recurrence.

Conclusion: There is no standardized operative approach or postoperative management for spontaneous CSF otorrhea. This study demonstrates that no surgical approach or the use of acetazolamide is associated with better postoperative outcomes. Larger population samples are necessary prior to making recommendations on the treatment and management of spontaneous CSF otorrhea.

Publication History

Article published online:
12 February 2021