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An Algorithm for CSF Leak Management in a Spectrum of Temporal Bone Pathologies

Koka Madhav, Raghunandhan Sampath kumar, Kiran Natarajan, Anand Kumar RS and Mohan Kameswaran

Introduction: A wide spectrum of temporal bone pathology can present with cerebrospinal fluid (CSF) leak. This originates from the defects in the temporal bone that can be spontaneous, traumatic, pathological and iatrogenic. Most common routes are from labyrinthine window dehiscence, along fracture lines, via inner ear malformations or by direct dural invasion due to middle ear pathology. Complications of CSF leak include otogenic meningitis, temporal lobe abscess and otic hydrocephalus.
Methods: This is a case review of three interesting patients, who presented with varied etiology of CSF leaks. Their complex pathology and the rationale in management of CSF leaks are highlighted. Case 1: Post road traffic accident (RTA) bilateral temporal bone fracture with unilateral CSF otorhinorrhea with total facial palsy with profound Sensorineural hearing loss (SNHL). Case 2: Petrous cholesteatoma recurring in a previous mastoid cavity with large tegmen and dural erosion, fungus cerbri and CSF leak. Case 3: Adolescent girl with unilateral cochleovestibular dysplasia presenting with recurrent meningitis due to spontaneous CSF otorhinorrhea.
Results: All patients had successful repair of defects to achieve complete arrest of leak by following meticulous approach with a multi-layered closure and post-operative management with neuro monitoring. Based on our experience we recommend a standard protocol for CSF leak repair in the temporal bone.
Conclusion: CSF otorrhea is a rare entity. Diagnosis is suspected through otorrhea, aural fullness, hearing loss and radiological investigations. Surgery is successful when managed at a tertiary referral centre having an experienced skull base team, using a protocol as suggested here.