Surgical Issues: Insights into UPPP, CPAP Use, and CSF Leaks

Some patients may have conditions which cause increased intracranial pressure, such as benign intracranial hypertension, obstructive sleep apnea, or obesity. Recurrent meningitis is the most significant complication from persistent CSF leakage, and surgery is often the only treatment, he said.

The intent of surgery is to prevent further leakage, but, more importantly, to re-establish the barrier between the subarachnoid space and the mastoid or middle ear, he said. Key surgical approaches include the transmastoid approach, middle fossa craniotomy, or a combination of the two. Different materials are commonly used for the repair of the defects.

Researchers conducted a retrospective study to compare different groups of patients who presented with spontaneous CSF otorrhea, and to compare autologous materials to bone cements used in the repairs.

A total of 17 patients who had undergone 19 surgeries met inclusion criteria. The patients had a mean age of 60; 12 were female, and five were male. All the female patients were obese (body mass index [BMI] greater than 30), whereas only two of the male patients were obese.

Fifteen patients underwent CT scans, MRI was performed on 12, and eight patients required MRI cisternography to confirm the location of the defect. Defects were most commonly found in the tegmen mastoideum and the tegmen tympani. There was a mean follow-up of 11 months.

As for the surgical approach, 14 underwent middle fossa craniotomy, and three had a transmastoid craniotomy (two were for posterior fossa defects, one for an isolated tegmen mastoideum defect). Two patients underwent a combined approach.

Nine different materials were used in the various surgeries, and were selected based on surgeon preference. Bone cement was the most common material used, and was utilized in 11 of the surgeries. Temporalis fascia was used in 10 of the surgeries.

Most surgeons used two materials, with an average of 2.7 materials used per case. The most materials used in a single operation were five, Dr. Kutz said.

Bone cement has certain advantages. For one, there’s no need to obtain autologous materials, he said. In addition, bone cement can be used to cover large areas, and is easy to apply. The disadvantages include infection, a potential for conductive hearing loss, and the possibility of reabsorption with time-although studies suggest bone cements hold up well over time, he said.

However, both autologous materials and bone cements were found to be equally efficacious in the study population. And the approach that we advocate for most cases is a middle fossa craniotomy, he said.