Surgical Approaches to Repair Tegmen Defects: A Systematic Review

Background: Defects of the lateral skull base require surgical intervention to prevent life-threatening complications including persistent CSF leaks, meningitis, and meningoencephaloceles. Many reconstruction methods have been described in the literature with outcome analyses yielding mixed results. To address this gap in knowledge, we performed a systematic review of surgical approaches to repair tegmen bony defects.

Methods: The overall research question was formulated according to the PICOS model: “In patients with tegmen defects, how do surgical approaches and reconstruction methods affect the rate of perioperative complications, length of hospital stay, and duration of follow up?” A systematic review of all relevant articles from January 2012 through March 2023 was performed using MEDLINE, EMbase, Web of Science, and SCOPUS databases. Studies were chosen that included at least 10 procedures; clearly defined the skull base defect, surgical approach, and grafting materials; and reported surgical outcomes.

Results: A total of 821 studies were reviewed. Of these, 42 met inclusion criteria yielding a total of 1,738 procedures (1,665 patients) for analysis. Patient age ranged from 5 to 94, and the most common presenting symptom was CSF otorrhea especially after PE tube placement. Most tegmen defects were spontaneous, but other etiologies included chronic otitis media, cholesteatoma, iatrogenic, or traumatic. Many were associated with encephaloceles, superior semicircular canal dehiscence (SSCD), or meningitis. Surgical repair was carried out via trans mastoid, middle cranial fossa, or a combined approach. The defect was repaired with a single or multilayer graft using various autologous (e.g., bone fascia, muscle, fat), xenogeneic (e.g., fetal bovine cartilage), bioactive (e.g., DuraGen, Tisseel, Surgicel, Gelfoam), or artificial (e.g., titanium) materials. Perioperative complications included persistent CSF leak, meningitis, altered mental status, facial paresis, and need for additional procedures.

Conclusion: Tegmen defects occur spontaneously at all ages but are most common in later adulthood. Defects often present with CSF otorrhea and can be associated with encephaloceles and SSCD. Lateral skull base defects are successfully repaired using middle fossa, trans mastoid or combined approaches that favor a multilayer graft containing various materials. Although perioperative complications have been reported, tegmen repair is typically well tolerated and has a low recurrence rate.

Publication History

Article published online:
05 February 2024