This document discusses cerebrospinal fluid (CSF) otorrhea, which is the presence of CSF within the temporal bone caused by a dural defect. CSF otorrhea can be caused by trauma, surgery, tumors, infections, or congenitally. Spontaneous CSF otorrhea in adults is often linked to abnormally located arachnoid granulations or congenital defects. Patients tend to be obese, middle-aged women who experience ear drainage or fullness. Diagnosis involves tests like beta-2 transferrin and imaging. Initial treatment focuses on bed rest, medications, and lumbar drains, while surgery aims to correct the bony defect using various materials and approaches.

1. CSF OTORRHEA
GAJALAKSHMI

2. • • Cerebrospinal fluid (CSF) otorrhea –Presence
of CSF within the confines of the temporal
bone
• Defect in the dura -abnormal communication
between subarachnoid space and
aircontaining space of temporal bone

3. The causes of CSF otorrhea
– Trauma (temporal bone fracture)
– Iatrogenic( skull base surgery)
– Neoplastic
– Infectious
– Congenital
• Spontaneous CSF otorrhea – Not related to the
above-mentioned causes

4. • Two categories of spontaneous cerebral spinal
fluid otorhhea:
(1) pediatric: ages 1–5years,
(2) adult: over 50 years of age

5. preformed pathways
• Pediatric :
– Enlarged fallopian canal
– Patent tympanomeningeal (Hyrtl’s) fissure
– Mondini dysplasia with communication
to internal auditory canal
• The adult form: enlarging arachnoid
granulations through the middle fossa
or posterior fossa surfaces of the temporal
bone.

6. • The most common locations for aberrant AGs are
1)lateral to the cribriform plate
2) along the floor of the middle fossa from the tegmen
tympani to the lateral surface of the sella turcica.
3)infrequently located in the posterior fossa plate of the
Temporal bone between the sigmoid sinus and bony
labyrinth and in the region of the jugular foramen.
• There may be an increased incidence of the AG on the
right side of the skull-right side predominance of the
venous system.

8. Pathophysiology of spontaneous CSF
otorrhea
• Congenital defect theory (Rao A et al ,2005) –
Defects of the middle fossa -tegmen enlarged
( constant CSF pressure) – Dural herniation –
thinning out-csf lea
• Arachnoid granulation theory( Gacek, et al
1999) – Abnormally located arachnoid
granulations –Minor CSF reservoirs. Abnormal
locations - decreased return to the venous
systems – Thinning and erosion of bone k

9. DEMOGRAPHY
• Mean ages: 60 years
• Mean BMI: 36.3 kg/m2
• Female predominance (F:M=2:1)
• association with
idiopathic intracranial hypertension( Schlosser
et al, 2008)
Empty or partially empty sella turcica
(Friedman et al, 2002 & John et al, 2010)

10. BMI - CSF otorrhea

11. Clinical presentation
• Young children:
– h/o recurrent Meningitis
– SNHL( Congenital anomalies )
• Obese middle-aged or elderly women: –
Decreased hearing or aural fullness with
middle ear effusions
– Persistent serous or clear discharge after
myringotomy

12. investigation
• β-2 transferrin
• MR CT WITH CONTRAST

13. management
• – Restricted nose blowing
• – Avoidance of straining
• – Bed rest and head elevation of 30 degrees –
• Use of antiemetics, antitussives and stool
softeners
• – Diuretics and fluid restriction
• – Lumbar drain

14. Surgical intervention
• Various approaches
– Transmastoid & translabyrinthine
– Middle fossa craniotomy
• Materials used to correct bony defect: – Bone,
cartilage, fascia, abdominal fat, silastic and
various combinations of autologous tissues.

15. • Transmastoid– Preferred approach for most
patients.
–Extracranial visualization of middle and posterior
fossa without damage of intracranial tissues
• Translabyrinthine approach – For patients with no
hearing – Remove all middle ear structure –
Occlude Eustachian tube with bone wax, muscle
and fascia – Obliteration of middle ear with
muscle or fat and close EAC

17. Mcf approach

18. • Multilayered Closure:
– highest rate of definitive closure
– lowest rate of recurrence

20. My references
• Richard R. Gacek-Ear Surgery
• Spontaneous Cerebrospinal Fluid Leaks: A Variant of
Benign Intracranial Hypertension Schlosser, Rodney
J;Woodworth, Bradford A;Eileen Maloney
Wilensky;Grady, M Sean;Bolger, William E The Annals
of Otology, Rhinology & Laryngology; Jul 2006; 115, 7;
• Significance of empty sella in cerebrospinal fluid leaks
RODNEY J. SCHLOSSER, MD, and WILLIAM E. BOLGER,
MD, Charleston, South Carolina, and Bethesda,
Maryland

21. • Adult onset spontaneous CSF otorrhea with
oval window fistula and recurrent meningitis:
MRI findings V. RUPA, DLO, MS, (ENT), A. JOB,
DLO, MS, (ENT), and V. RAJSHEKHAR, MCh,
(NEURO),* Tamil Nadu, India