Brandon Isaacson MD, FACSUT Southwestern Medical CenterEmail:
[email protected]
Objective: To determine the prevalence of elevated intracranial
hypertension in patients with spontaneous cerebrospinal fluid
otorrhea (SCSFO).
Study design: Case series with chart review
Setting: Tertiary care referral center
Subjects and Methods: Patients included have undergone operative
repair of spontaneous CSF otorrhea between January 2007 and May
2012. Lumbar puncture opening pressure was used to measure
intracranial pressure (ICP) 6 weeks after surgery. Preoperative
magnetic resonance imaging was also reviewed for evidence of
elevated ICP.
Results: : Thirty-eight patients underwent operative repair of
spontaneous cerebrospinal fluid otorrhea. Of these, 22 underwent
postoperative lumbar puncture with measurement of the opening
pressure. The opening pressure was elevated (>20 cm/H20) in 8
patients (36.4%). Preoperative magnetic resonance imaging was
available for review by a neuroradiologist in 27 patients.
Radiographic evidence of elevated intracranial pressure was present
in 48.1% of patients.
Conclusion: Elevated intracranial pressure is common in patients
with spontaneous cerebrospinal fluid otorrhea. However, when
directly measured by lumbar puncture opening pressure, a minority
of patients has elevated intracranial pressure.
Elevated Intracranial Pressure in Patients with Spontaneous
Cerebrospinal Fluid Otorrhea
Kyle P Allen MD, MPH1, Carlos L. Perez MD2, J. Walter Kutz, Jr.,
MD1, Peter S. Roland, MD1, Deniz Gerecci3, Brandon Isaacson,
MD11Department Of Otolaryngology, UT Southwestern Medical Center
(UTSW), 2Department of Radiology, UTSW, 3UTSW Medical School
After institutional review board approval, patients undergoing
repair SCSFO at a single, tertiary care referral center between
January 2007 and May 2012 were identified. Patients with CSF
fistula due an etiology of trauma, cholesteatoma, or neoplasm were
excluded from the analysis. Operative repair was performed via a
middle fossa or transmastoid approach.
When available, preoperative magnetic resonance imaging (MRI)
was reviewed for evidence of elevated ICP (empty sella, optic nerve
dilation, reverse cupping of the optic disc, tortuous/elongated
optic nerve, flattened sclera, or Meckel’s cave diverticula).
Patient underwent lumbar puncture opening pressure (LPOP)
measurement 6 weeks after operative repair to measure intracranial
pressure.
While elevated ICP is a common finding in patients with SCSFO,
only a minority of patients have elevated pressure by LPOP or MRI
findings. This may indicated that while elevated ICP may contribute
to the development of some cases of SCSFO, it is not a universal
finding. Other etiologies, such as a congenitally thin skull base
or aberrant arachnoid granulations may be a more common etiology of
SCSFO.
INTRODUCTION
CONCLUSIONS
METHODS
REFERENCES
ABSTRACT RESULTSSpontaneous cerebrospinal fluid otorrhea (SCSFO)
occurs when cerebrospinal fluid (CSF) fills the aerated confines of
the temporal bone in the absence of trauma, chronic infection,
neoplasm, or iatrogenic cause. The exact etiology is unclear, but
may be due to erosion of the tegmen by aberrant arachnoid
granulations or constant pulsation of the temporal lobe against a
congenitally thin tegmen resulting in a bony and dural defect.1
More recently, the role of increased intracranial pressure (ICP)
and its correlation with idiopathic intracranial hypertension (IIH)
in the pathogenesis SCSFO has come to the forefront. The upper
limit of normal for lumbar puncture opening pressure (LPOP) is 20
cm/H20, however, some consider pressures up to 25-28 cm/H20 to be
normal.2 The modified Dandy criteria for the diagnosis of IIH
require an opening pressure greater than 25 cm/H20, among other
criteria.3It has been proposed that spontaneous CSF leaks of
sinonasal and temporal bone origin may be a result of IIH.4,5 In
one study of spontaneous CSF leaks of sinonasal origin, 72% of
patients (8 of 11) were noted to have a LPOP greater than 20
cm/H20, and 54.5% (6 of 11) had a pressure greater than 25 cm/H20.4
Empty sella syndrome (ESS), a radiographic correlate of elevated
ICP, has an increased prevalence in patients with spontaneous CSF
of sinonasal and temporal bone origin.4,6
This retrospective review was undertaken to examine the
prevalence of elevated intracranial pressure in a series of
patients who have undergone repair of SCSFO.
Patient characteristics
Operative repair of SCSFO was performed for 40 ears in 38
consecutive patients. Demographic for the patients is included in
Table 1. The majority of patients were female (76.3%), and the left
ear was more commonly involved in 65% of affected ears (26/40). Two
patients had bilateral SCSFO and underwent staged bilateral
repairs. By body mass index (BMI) criteria, 30 patients (78.9%)
were obese (BMI >30 kg/m2).
Preoperative Magnetic Resonance Imaging
Preoperative magnetic resonance imaging was available for review
by a neuroradiologist in 27 patients. Radiographic evidence of
elevated intracranial pressure was present in 13 (48.1%) patients.
Radiographic findings are listed in Table 2.
RESULTS
Figure 1: Coronal T2 MRI and CT of the temporal bone
demonstrating a left meningoencephalocele (arrows) in a 59 year-old
male patient.
1. Gacek RR, Gacek MR, Tart R. Adult spontaneous cerebrospinal
fluid otorrhea: diagnosis and management. Am J Otol. 1999; 20:
770-76.
2. Whiteley W, Al-Shahi R, Warlow CP, Zeidler M, Lueck CJ. CSF
opening pressure: Reference interval and the effect of body mass
index. Neurology. 2006; 67: 1690-1691.
3. Smith J.L.: Whence pseudotumor cerebri?. J Clin
Neuroophthalmol. 1985; 5: 55-56.
4. Schlosser RJ, Woodworth BA, Wilensky EM, Grady MS, Bolger WE.
Spontaneous cerebrospinal fluid leaks: a variant of benign
intracranial hypertension. Ann Otol, Rhin & Laryng. 2006; 115:
495-500.
5. LeVay AJ, Kveton JF. Relationship between obesity,
obstructive sleep apnea, and spontaneous cerebrospinal fluid
otorrhea. Laryngoscope. 2008; 118: 275-8.
6. Prichard CH, Isaacson B, Oghalai JS, Coker NJ, Vrabec JF.
Adult spontaneous CSF otorrhea: correlation with radiographic empty
sella. J Oto HNS. 2006; 134: 767-71.
Patients 38Female 29 (76.3%
Male 9 (23.7%)
CSF Otorrhea
Unilateral 29 (94.7%)
Bilateral 2 (5.3%)
Age
Range (years) 40-75
Mean (years) 60.3
BMI
Range (kg/m2) 24.2-57.8
Mean (kg/m2) 36.8
Obese (BMI >30 kg/m2) 30 (78.9%)
Table 1
Lumbar Opening Pressure Measurements
Twenty-two patients underwent postoperative LPOP measurement .
Opening pressures ranged from 10-55 cm/H20 with a mean of 19.4
cm/H20. The opening pressure was elevated (>20 cm/H20) in 8
patients (36.4%). Two patients (9.1%) met the modified Dandy LPOP
criteria for IIH (>25 cm/H20). All patients with elevated LPOP
were female. There were no significant differences in age or BMI in
patients with or without elevated LPOP.
MRIFindings # %
Total Patients 27
Empty Sella 10 37.0
Meckel's Cave Diverticula 9 33.3
Optic Nerve Dilation 4 14.8
Tortuous/Elongated Optic Nerve 3 11.1
Flattened Sclera 1 3.7
Reverse Cupping of the Optic Disc 0
0
Evidence of Elevated ICP 13 48.1Table 2
Intracranial pressure measurement by lumbar puncture opening
pressure
Figure 2: Example of an empty sella (arrow) demonstrated on a
coronal T2 MRI in a 56 year-old female patient with SCSFO and
elevated LPOP.
Figure 3: Bilateral Meckel’s cave diverticula (arrows) in a 68
year-old male patient with SCSFO.
