Top

European Archives of Oto-Rhino-Laryngology

Published in:

01-10-2016 | Otology

Management of CSF leakage after microsurgery for vestibular schwannoma via the middle cranial fossa approach

Authors: Matthias Scheich, Christian Ginzkey, Desiree Ehrmann-Müller, Wafaa Shehata-Dieler, Rudolf Hagen

Published in: European Archives of Oto-Rhino-Laryngology | Issue 10/2016

Abstract

Microsurgery is one of the primary current standard options for the treatment of vestibular schwannoma (VS). Especially the middle cranial fossa (MCF) approach is a safe and efficacious technique for the preservation of hearing and facial nerve function in small VS. Postoperative complications are rare, although a leakage of cerebrospinal fluid (CSF) is common. The aim of this study was to analyze postoperative CSF leaks and to describe strategies for postoperative treatment. Between October 2005 and May 2012, 148 patients suffering from VS and selected for microsurgery via the MCF approach were treated in our department. Postoperative CSF leakage occurred in 19 patients. We found a leakage via the Eustachian tube into the nasopharynx in 18 patients and one case of incisional leakage. In 13 cases leaking stopped within 5 days by conservative management including bed rest and intravenous (i.v) antibiotics. Five patients needed lumbar drainage (LD) and only two patients had to undergo revision surgery to seal and pack the mastoid. Analyzed risk factors were age, gender, tumor size and pneumatization of the mastoid. Only the latter showed a significant influence on CSF leakage. We could demonstrate that a stepwise strategy is needed for successful treatment of CSF leaks.

Meyer TA, Canty PA, Wilkinson EP, Hansen MR, Rubinstein JT, Gantz BJ (2006) Small acoustic neuromas: surgical outcomes versus observation or radiation. Otol Neurotol 27(3):380–392CrossRefPubMed

Sughrue ME, Yang I, Aranda D, Kane AJ, Parsa AT (2010) Hearing preservation rates after microsurgical resection of vestibular schwannoma. J Clin Neurosci 17(9):1126–1129. doi:10.1016/j.jocn.2010.01.018 CrossRefPubMed

Sanna M, Taibah A, Russo A, Falcioni M, Agarwal M (2004) Perioperative complications in acoustic neuroma (vestibular schwannoma) surgery. Otol Neurotol 25(3):379–386CrossRefPubMed

Ansari SF, Terry C, Cohen-Gadol AA (2012) Surgery for vestibular schwannomas: a systematic review of complications by approach. Neurosurg Focus 33(3):E14. doi:10.3171/2012.6.FOCUS12163 CrossRefPubMed

Arts HA, Telian SA, El-Kashlan H, Thompson BG (2006) Hearing preservation and facial nerve outcomes in vestibular schwannoma surgery: results using the middle cranial fossa approach. Otol Neurotol 27(2):234–241. doi:10.1097/01.mao.0000185153.54457.16 CrossRefPubMed

DeMonte F, Gidley PW (2012) Hearing preservation surgery for vestibular schwannoma: experience with the middle fossa approach. Neurosurg Focus 33(3):E10. doi:10.3171/2012.7.FOCUS12172 CrossRefPubMed

Gjuric M, Wigand ME, Wolf SR (2001) Enlarged middle fossa vestibular schwannoma surgery: experience with 735 cases. Otol Neurotol 22(2):223–230 (discussion 230-221) CrossRefPubMed

Ginzkey C, Scheich M, Harnisch W, Bonn V, Ehrmann-Müller D, Shehata-Dieler W, Mlynski R, Hagen R (2012) Outcome on hearing and facial nerve function in microsurgical treatment of small vestibular schwannoma via the middle cranial fossa approach. Eur Arch Otorhinolaryngol. doi:10.1007/s00405-012-2074-8

Gjuric M, Mitrecic MZ, Greess H, Berg M (2007) Vestibular schwannoma volume as a predictor of hearing outcome after surgery. Otol Neurotol 28(6):822–827. doi:10.1097/MAO.0b013e318068b2b0 CrossRefPubMed

10.

Höhmann D, Dornhoffer JL, Helms J (1994) Auditory results after transtemporal removal of acoustic neurinoma [in German]. HNO 42(9):541–545PubMed

11.

Dornhoffer JL, Helms J, Höhmann DH (1995) Hearing preservation in acoustic tumor surgery: results and prognostic factors. Laryngoscope 105(2):184–187. doi:10.1288/00005537-199502000-00014 CrossRefPubMed

12.

Scheich M, Ginzkey C, Harnisch W, Ehrmann-Müller D, Shehata-Dieler W, Hagen R (2012) Use of flexible CO₂ laser fiber in microsurgery for vestibular schwannoma via the middle cranial fossa approach. Eur Arch Otorhinolaryngol 269(5):1417–1423. doi:10.1007/s00405-011-1791-8 CrossRefPubMed

13.

Schwager K, Baier G, Helms J, Hagen R (2008) Results in otosurgically treated patients with acoustic neuroma. Part 2: hearing results after middle fossa approach [in German]. Laryngorhinootologie 87(9):629–633. doi:10.1055/s-2007-995705 CrossRefPubMed

14.

Baier G, Schwager K, Helms J, Hagen R (2008) Results in otosurgically treated patients with acoustic neuroma. Part 1: facial nerve function after translabyrinthine and middle fossa resection [in German]. Laryngorhinootologie 87(8):565–572. doi:10.1055/s-2007-995644 CrossRefPubMed

15.

Scheich M, Ginzkey C, Mlynski R, Hagen R (2013) Postoperative complications after surgery for vestibular schwannoma via the MCF approach [in German]. Laryngorhinootologie 92(12):823–827. doi:10.1055/s-0033-1354379 CrossRefPubMed

16.

Becker SS, Jackler RK, Pitts LH (2003) Cerebrospinal fluid leak after acoustic neuroma surgery: a comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches. Otol Neurotol 24(1):107–112CrossRefPubMed

17.

Kanzaki J, Ogawa K, Tsuchihashi N, Inoue Y, Yamamoto M, Ikeda S (1991) Postoperative complications in acoustic neuroma surgery by the extended middle cranial fossa approach. Acta Otolaryngol Suppl 487:75–79CrossRefPubMed

18.

Minovi A, Mangold R, Kollert M, Hofmann E, Draf W, Bockmühl U (2005) Functional results, cognitive and effective quality of life disturbances after trans-temporal resection of acoustic neuroma [in German]. Laryngorhinootologie 84(12):915–920. doi:10.1055/s-2005-870573 CrossRefPubMed

19.

Pollock BE, Driscoll CL, Foote RL, Link MJ, Gorman DA, Bauch CD, Mandrekar JN, Krecke KN, Johnson CH (2006) Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery. Neurosurgery 59(1):77–85 (discussion 77–85) CrossRefPubMed

20.

Sameshima T, Fukushima T, McElveen JT Jr, Friedman AH (2010) Critical assessment of operative approaches for hearing preservation in small acoustic neuroma surgery: retrosigmoid vs middle fossa approach. Neurosurgery 67(3):640–644. doi:10.1227/01.NEU.0000374853.97891.FB CrossRefPubMed

21.

Slattery WH 3rd, Francis S, House KC (2001) Perioperative morbidity of acoustic neuroma surgery. Otol Neurotol 22(6):895–902CrossRefPubMed

22.

Weber PC, Gantz BJ (1996) Results and complications from acoustic neuroma excision via middle cranial fossa approach. Am J Otol 17(4):669–675PubMed

23.

Merkus P, Taibah A, Sequino G, Sanna M (2010) Less than 1 % cerebrospinal fluid leakage in 1803 translabyrinthine vestibular schwannoma surgery cases. Otol Neurotol 31(2):276–283. doi:10.1097/MAO.0b013e3181cc06ad CrossRefPubMed

24.

Samii M, Matthies C (1997) Management of 1000 vestibular schwannomas (acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them. Neurosurgery 40(1):11–21 (discussion 21–13) PubMed

25.

Selesnick SH, Liu JC, Jen A, Carew JF (2004) Management options for cerebrospinal fluid leak after vestibular schwannoma surgery and introduction of an innovative treatment. Otol Neurotol 25(4):580–586CrossRefPubMed

26.

Falcioni M, Romano G, Aggarwal N, Sanna M (2008) Cerebrospinal fluid leak after retrosigmoid excision of vestibular schwannomas. Otol Neurotol 29(3):384–386. doi:10.1097/MAO.0b013e31816021e3 CrossRefPubMed

27.

Lazard DS, Tosello M, Bozorg-Grayeli A, Vitte E, Bouccara D, Kalamarides M, Sterkers O (2011) Early complications and symptoms of cerebellopontine angle tumor surgery: a prospective analysis. Eur Arch Otorhinolaryngol 268(11):1575–1582. doi:10.1007/s00405-011-1539-5 CrossRefPubMed

28.

House WF (1961) Surgical exposure of the internal auditory canal and its contents through the middle, cranial fossa. Laryngoscope 71:1363–1385. doi:10.1288/00005537-196111000-00004 CrossRefPubMed

29.

Fisch U (1969) Transtemporal extralabyrinthine operations on the internal auditory canal, the eighth and the seventh cranial nerves. In: Yasargil G (ed) Microsurgery applied to neurosurgery. Thieme, Stuttgart, pp 195–210

30.

Brackmann DE, House JR 3rd, Hitselberger WE (1994) Technical modifications to the middle fossa craniotomy approach in removal of acoustic neuromas. Am J Otol 15(5):614–619PubMed

31.

Stieglitz LH, Giordano M, Gerganov V, Raabe A, Samii A, Samii M, Lüdemann WO (2010) Petrous bone pneumatization is a risk factor for cerebrospinal fluid fistula following vestibular schwannoma surgery. Neurosurgery 67(2):509–515. doi:10.1227/NEU.0b013e3181f88884 PubMed

32.

Fishman AJ, Marrinan MS, Golfinos JG, Cohen NL, Roland JT Jr (2004) Prevention and management of cerebrospinal fluid leak following vestibular schwannoma surgery. Laryngoscope 114(3):501–505. doi:10.1097/00005537-200403000-00022 CrossRefPubMed

33.

Hoffman RA (1994) Cerebrospinal fluid leak following acoustic neuroma removal. Laryngoscope 104(1 Pt 1):40–58. doi:10.1288/00005537-199401000-00009 PubMed

34.

Selesnick SH, Liu JC, Jen A, Newman J (2004) The incidence of cerebrospinal fluid leak after vestibular schwannoma surgery. Otol Neurotol 25(3):387–393CrossRefPubMed

35.

Mangus BD, Rivas A, Yoo MJ, Alvarez J, Wanna GB, Haynes DS, Bennett ML (2011) Management of cerebrospinal fluid leaks after vestibular schwannoma surgery. Otol Neurotol 32(9):1525–1529. doi:10.1097/MAO.0b013e318232e4a4 CrossRefPubMedPubMedCentral

36.

Brennan JW, Rowed DW, Nedzelski JM, Chen JM (2001) Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment. J Neurosurg 94(2):217–223. doi:10.3171/jns.2001.94.2.0217 CrossRefPubMed

37.

Heman-Ackah SE, Golfinos JG, Roland JT Jr (2012) Management of surgical complications and failures in acoustic neuroma surgery. Otolaryngol Clin North Am 45(2):455–470. doi:10.1016/j.otc.2011.12.012 CrossRefPubMed

38.

Bryce GE, Nedzelski JM, Rowed DW, Rappaport JM (1991) Cerebrospinal fluid leaks and meningitis in acoustic neuroma surgery. Otolaryngol Head Neck Surg 104(1):81–87CrossRefPubMed

39.

Stieglitz LH, Giordano M, Gerganov VM, Samii A, Samii M, Lüdemann WO (2011) How obliteration of petrosal air cells by vestibular schwannoma influences the risk of postoperative CSF fistula. Clin Neurol Neurosurg 113(9):746–751. doi:10.1016/j.clineuro.2011.07.029 CrossRefPubMed

40.

Van Abel KM, Carlson ML, Driscoll CL, Neff BA, Link MJ (2014) Vestibular schwannoma surgery in the elderly: a matched cohort study. J Neurosurg 120(1):207–217. doi:10.3171/2013.6.JNS122433 CrossRefPubMed

41.

Lüdemann WO, Stieglitz LH, Gerganov V, Samii A, Samii M (2008) Fat implant is superior to muscle implant in vestibular schwannoma surgery for the prevention of cerebrospinal fluid fistulae. Neurosurgery 63(1 Suppl):38–42. doi:10.1227/01.neu.0000335009.53122.a3

42.

Yamakami I, Uchino Y, Kobayashi E, Yamaura A (2003) Computed tomography evaluation of air cells in the petrous bone–relationship with postoperative cerebrospinal fluid rhinorrhea. Neurol Med Chir 43(7):334–338 (discussion 339) CrossRef

43.

Faure A, Masse H, Gayet-Delacroix M, Khalfallah M, Bordure P, Hamel O, Raoul S, Leborgne J, Robert R (2003) What is the arcuate eminence? Surg Radiol Anat 25(2):99–104. doi:10.1007/s00276-003-0102-5 CrossRefPubMed

44.

Chamoun R, MacDonald J, Shelton C, Couldwell WT (2012) Surgical approaches for resection of vestibular schwannomas: translabyrinthine, retrosigmoid, and middle fossa approaches. Neurosurg Focus 33(3):E9. doi:10.3171/2012.6.FOCUS12190 CrossRefPubMed

45.

Fisch U (1978) Otoneurosurgical approach to acoustic neurinomas. In: Krayenbühl H (ed) Microsurgical approach to cerebro-spinal lesions, vol 9., Progress in neurological surgeryKarger, Basel, pp 318–336

46.

Arlt F, Trantakis C, Krupp W, Renner C, Winkler D, Strauss G, Meixensberger J (2011) Cerebrospinal fluid leak after microsurgical surgery in vestibular schwannomas via retrosigmoidal craniotomy. Neurol Res 33(9):947–952. doi:10.1179/1743132811Y.0000000042 CrossRefPubMed

47.

Kalamarides M, Grayeli AB, Bouccara D, Redondo A, Rey A, Sterkers O (2004) Opening cerebrospinal fluid pressure guides the management of cerebrospinal fluid leakage after acoustic neuroma surgery. Otol Neurotol 25(5):769–772CrossRefPubMed

48.

Shelton C, Brackmann DE, House WF, Hitselberger WE (1989) Middle fossa acoustic tumor surgery: results in 106 cases. Laryngoscope 99(4):405–408. doi:10.1288/00005537-198904000-00009 CrossRefPubMed

49.

Rabelo de Freitas M, Russo A, Sequino G, Piccirillo E, Sanna M (2012) Analysis of hearing preservation and facial nerve function for patients undergoing vestibular schwannoma surgery: the middle cranial fossa approach versus the retrosigmoid approach-personal experience and literature review. Audiol Neurootol 17(2):71–81. doi:10.1159/000329362 CrossRefPubMed

50.

Lebowitz RA, Hoffman RA, Roland JT Jr, Cohen NL (1995) Autologous fibrin glue in the prevention of cerebrospinal fluid leak following acoustic neuroma surgery. Am J Otol 16(2):172–174PubMed

51.

Shorter CD, Connor DE Jr, Thakur JD, Gardner G, Nanda A, Guthikonda B (2012) Repair of middle fossa cerebrospinal fluid leaks using a novel combination of materials: technical note. Neurosurg Focus 32(6):8. doi:10.3171/2012.4.FOCUS1258 CrossRef

Title: Management of CSF leakage after microsurgery for vestibular schwannoma via the middle cranial fossa approach
Authors: Matthias Scheich
Christian Ginzkey
Desiree Ehrmann-Müller
Wafaa Shehata-Dieler
Rudolf Hagen
Publication date: 01-10-2016
Publisher: Springer Berlin Heidelberg
Published in: European Archives of Oto-Rhino-Laryngology / Issue 10/2016
Print ISSN: 0937-4477
Electronic ISSN: 1434-4726
DOI: https://doi.org/10.1007/s00405-015-3891-3

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Management of CSF leakage after microsurgery for vestibular schwannoma via the middle cranial fossa approach

Abstract

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 10/2016

Neutrophil to lymphocyte ratio in allergic rhinitis

Clinical and morphological aspects of adenocarcinomas of the intestinal type in the inner nose: a retrospective multicenter analysis

The effects of a canalplasty and a canal wall reconstruction on perceived sound quality: preliminary results

Should patients with laryngeal small cell neuroendocrine carcinoma receive prophylactic cranial irradiation?

Woodworkers and the inflammatory effects of softwood/hardwood dust: evidence from nasal cytology

A proposal for a level for parapharyngeal extension of parotid gland