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J Neurol Surg B Skull Base 2022; 83(06): 653-662
DOI: 10.1055/a-1933-3958
Review Article

Temporal Bone Skull Base Defects—The Value and Importance of Early Based Detection to Prevent Late Costly Morbidity and Mortality

Thomas Hendriks 
1   Department of Otolaryngology Head and Neck Surgery, Fiona Stanley Hospital, Murdoch, Australia
,
Claudia Kirsch 
2   Yale University School of Medicine Department of Radiology and Biomedical Imaging, New Haven, Connecticut, United States
3   Mount Sinai Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
4   Department of Clinical Dentistry, University of Sheffield, Sheffield, South Yorkshire, England
,
Daren Gibson
5   Department of Medical Imaging, Fiona Stanley Hospital Ringgold Standard Institution, Murdoch, Australia
,
Jafri Kuthubutheen
6   Department of Ear, Nose and Throat Surgery, Fiona Stanley Hospital Ringgold Standard Institution, Murdoch, Australia
7   Department of Otolaryngology and Head and Neck Surgery, Sir Charles Gairdner Hospital Ringgold Standard Institution, Nedlands, Australia
8   Department of Western ENT, South Perth Hospital, Como, Australia
9   School of Surgery, The University of Western Australia Ringgold Standard Institution, Perth, Australia
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Introduction

Acute bacterial meningitis is a devastating illness with high morbidity and mortality, involving leptomeningeal inflammation that may manifest as sudden onset fever, nuchal rigidity, and altered mental status.[1] [2] Common acquired causative pathogens in the community include Streptococcus pneumoniae and Neisseria meningitidis.[3] A high-grade bacteremia with central nervous system (CNS) invasion is the presumed transmission route in the majority of patients diagnosed with bacterial meningitis; however, upper airway mucosal infections and/or co-existent skull base bone defects can potentiate direct spread of bacteria into the CNS.[4] Examples of this are intracranial complications of otitis media (OM) requiring a prompt and accurate diagnosis to avoid significant disability.[5] Complicated OM is common both at a primary care level and as a predisposing factor in up to one-quarter of patients who develop acute bacterial meningitis.[6] The typical demographic affected by acute OM secondary to Streptococcus pneumoniae are pediatric patients under the age of two, or adults over 50 years.[7] An osseous tegmen defect can also potentially facilitate the spread of infection from the middle ear (ME) cleft to the middle cranial fossa (MCF). These defects can be congenital, such as incomplete partition, enlarged vestibular aqueducts, or persistent Hyrtl's fissure, posttraumatic or secondary to local erosive cholesteatomas, and in some cases iatrogenic following otological surgery. Approximately 5% of community-acquired meningitides are believed to be from anatomical skull base defects, with an increased risk of recurrent meningitis.[8] [9] Additionally, unfavorable prognostic outcomes associated with bacterial meningitis include pneumococcal infection and the presence of OM or sinusitis often co-existing with skull base defects.[2] Acquired skull base defects are an increasingly recognized condition related to spontaneous cerebrospinal fluid (sCSF) otorrhea. sCSF otorrhea has increased in incidence, almost doubling in the past decade, along with concomitant increases in obesity worldwide and benign intracranial hypertension (BIH), although the exact incidence and prevalence of sCSF from idiopathic intracranial hypertension (IIHT) and obesity remains unknown.[10] [11] In sCSF leakage, the CSF may extend through temporal bone defects into the ME and/or mastoid.[12] [13] Affected patients are typically obese middle-aged females presenting with unilateral aural fullness, conductive hearing loss, and occasionally frank otorrhoea.[10] [11] [14] [15] [16] Biochemical analysis of ME fluid for β-trace protein (BTP) and radiological temporal bone computed tomography (CT) or thin section T2-weighted magnetic resonance imaging (MRI) aid in identifying skull base bony defects and aberrant arachnoid granulations. Patients with skull base defects may be predisposed to risks of ascending intracranial sepsis and meningitis.[10] [11] [12] Prior published research by this group in a cohort of 28 sCSF patients, revealed two patients (7%) with otogenic meningitis presumed due to undiagnosed sCSF.[17] Additional literature has noted recurrent meningitis from temporal bone CSF leakage.[10] [18] [19] [20]

Because the incidence of sCSF is increasing, the goal of this value-based study was to retrospectively assess clinical and imaging features of bacterial meningitis with presumed otogenic etiology, compared with patients with sCSF. Currently, there is a paucity of detailed, published data quantifying the potential relationship between sCSF and risk of meningitis. This value-based study assessed 20 patients with acute otogenic meningitis, comparing clinical features to sCSF patients, for demographic features that may predispose to tegmen defects. Patients at risk of sCSF may benefit from workflows with early radiographic skull base and temporal bones assessment via temporal bone CT or MRI T2 thin section imaging evaluating for tegmen thinning, bony defects, or aberrant arachnoid granulations. In the ideal value-based health-care setting, earlier radiographic identification of tegmen defects with specialist ear, nose, and throat (ENT) treatment, may prevent progressing to acute otogenic meningitis and its associated increased morbidity and mortality.



Publication History

Received: 30 December 2021

Accepted: 24 August 2022

Accepted Manuscript online:
30 August 2022

Article published online:
12 November 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Tunkel AR, Hasbun R, Bhimraj A. et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017; 64 (06) e34-e65
    CrossrefPubMedGoogle Scholar
  • 2 van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351 (18) 1849-1859
    CrossrefPubMedGoogle Scholar
  • 3 van de Beek D, Brouwer M, Hasbun R, Koedel U, Whitney CG, Wijdicks E. Community-acquired bacterial meningitis. Nat Rev Dis Primers 2016; 2: 16074
    CrossrefPubMedGoogle Scholar
  • 4 Hoffman O, Weber RJ. Pathophysiology and treatment of bacterial meningitis. Ther Adv Neurol Disord 2009; 2 (06) 1-7
    CrossrefPubMedGoogle Scholar
  • 5 Yorgancılar E, Yildirim M, Gun R. et al. Complications of chronic suppurative otitis media: a retrospective review. Eur Arch Otorhinolaryngol 2013; 270 (01) 69-76
    CrossrefPubMedGoogle Scholar
  • 6 Celal A, Faruk GM, Salih H, Kemal CM, Serife A, Faruk KO. Characteristics of acute bacterial meningitis in Southeast Turkey. Indian J Med Sci 2004; 58 (08) 327-333
    PubMedGoogle Scholar
  • 7 Oordt-Speets AM, Bolijn R, van Hoorn RC, Bhavsar A, Kyaw MH. Global etiology of bacterial meningitis: a systematic review and meta-analysis. PLoS One 2018; 13 (06) e0198772
    CrossrefPubMedGoogle Scholar
  • 8 Adriani KS, Brouwer MC, van de Beek D. Risk factors for community-acquired bacterial meningitis in adults. Neth J Med 2015; 73 (02) 53-60
    PubMedGoogle Scholar
  • 9 Adriani KS, van de Beek D, Brouwer MC, Spanjaard L, de Gans J. Community-acquired recurrent bacterial meningitis in adults. Clin Infect Dis 2007; 45 (05) e46-e51
    CrossrefPubMedGoogle Scholar
  • 10 Thomeer HG, Schreurs C, van Doormaal TP, Straatman LV. Management and outcomes of spontaneous cerebrospinal fluid otorrhoea. Front Surg 2020; 7: 21
    CrossrefPubMedGoogle Scholar
  • 11 Stucken EZ, Selesnick SH, Brown KD. The role of obesity in spontaneous temporal bone encephaloceles and CSF leak. Otol Neurotol 2012; 33 (08) 1412-1417
    CrossrefPubMedGoogle Scholar
  • 12 Hendriks T, Bala A, Rodrigues S, Kuthubutheen J. Spontaneous cerebrospinal fluid (CSF) otorrhoea in Western Australia—an emerging entity?. Aust J Otolaryngol Feb 2019;2
    PubMedGoogle Scholar
  • 13 Nelson RF, Hansen KR, Gantz BJ, Hansen MR. Calvarium thinning in patients with spontaneous cerebrospinal fluid leak. Otol Neurotol 2015; 36 (03) 481-485
    CrossrefPubMedGoogle Scholar
  • 14 Brown NE, Grundfast KM, Jabre A, Megerian CA, O'Malley Jr BW, Rosenberg SI. Diagnosis and management of spontaneous cerebrospinal fluid-middle ear effusion and otorrhea. Laryngoscope 2004; 114 (05) 800-805
    CrossrefPubMedGoogle Scholar
  • 15 Gacek RR, Gacek MR, Tart R. Adult spontaneous cerebrospinal fluid otorrhea: diagnosis and management. Am J Otol 1999; 20 (06) 770-776
    PubMedGoogle Scholar
  • 16 Rao N, Redleaf M. Spontaneous middle cranial fossa cerebrospinal fluid otorrhea in adults. Laryngoscope 2016; 126 (02) 464-468
    CrossrefPubMedGoogle Scholar
  • 17 Schlosser RJ, Bolger WE. Spontaneous nasal cerebrospinal fluid leaks and empty sella syndrome: a clinical association. Am J Rhinol 2003; 17 (02) 91-96
    CrossrefPubMedGoogle Scholar
  • 18 Li YC, Chen CY, Wu KH, Kuo HT, Wu HP. Recurrent Streptococcus Pneumoniae 23 F meningitis due to cerebrospinal fluid leakage from the ear cannel: a case report. BMC Pediatr 2015; 15: 195
    CrossrefPubMedGoogle Scholar
  • 19 Wang HS, Kuo MF, Huang SC. Diagnostic approach to recurrent bacterial meningitis in children. Chang Gung Med J 2005; 28 (07) 441-452
    PubMedGoogle Scholar
  • 20 Wen HY, Chou ML, Lin KL, Kao PF, Chen JF. Recurrence of pneumococcal meningitis due to primary spontaneous cerebrospinal fluid fistulas. Chang Gung Med J 2001; 24 (11) 724-728
    PubMedGoogle Scholar
  • 21 Hendriks T, Bala A, Kuthubutheen J. Spontaneous cerebrospinal fluid leaks of the temporal bone - clinical features and management outcomes. Auris Nasus Larynx 2022; 49 (01) 26-33
    CrossrefPubMedGoogle Scholar
  • 22 Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: report of 93 cases. J Laryngol Otol 2000; 114 (02) 97-100
    CrossrefPubMedGoogle Scholar
  • 23 Ter Horst L, Brouwer MC, van der Ende A, van de Beek D. Community-acquired bacterial meningitis in adults with cerebrospinal fluid leakage. Clin Infect Dis 2020; 70 (11) 2256-2261
    CrossrefPubMedGoogle Scholar
  • 24 Marom T, Shemesh S, Habashi N, Gluck O, Tamir SO. Adult otogenic meningitis in the pneumococcal conjugated vaccines era. Int Arch Otorhinolaryngol 2020; 24 (02) e175-e181
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 LeVay AJ, Kveton JF. Relationship between obesity, obstructive sleep apnea, and spontaneous cerebrospinal fluid otorrhea. Laryngoscope 2008; 118 (02) 275-278
    CrossrefPubMedGoogle Scholar
  • 26 Nelson RF, Gantz BJ, Hansen MR. The rising incidence of spontaneous cerebrospinal fluid leaks in the United States and the association with obesity and obstructive sleep apnea. Otol Neurotol 2015; 36 (03) 476-480
    CrossrefPubMedGoogle Scholar
  • 27 Rabbani CC, Saltagi MZ, Manchanda SK, Yates CW, Nelson RF. Prevalence of obstructive sleep apnea (OSA) in spontaneous cerebrospinal fluid (CSF) leaks: a prospective cohort study. Otol Neurotol 2018; 39 (06) e475-e480
    CrossrefPubMedGoogle Scholar
  • 28 Allen KP, Perez CL, Kutz JW, Gerecci D, Roland PS, Isaacson B. Elevated intracranial pressure in patients with spontaneous cerebrospinal fluid otorrhea. Laryngoscope 2014; 124 (01) 251-254
    CrossrefPubMedGoogle Scholar
  • 29 Bakhsheshian J, Hwang MS, Friedman M. Association between obstructive sleep apnea and spontaneous cerebrospinal fluid leaks: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg 2015; 141 (08) 733-738
    CrossrefPubMedGoogle Scholar
  • 30 Schlosser RJ, Wilensky EM, Grady MS, Bolger WE. Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks. Am J Rhinol 2003; 17 (04) 191-195
    CrossrefPubMedGoogle Scholar
  • 31 Beggs CB, Magnano C, Shepherd SJ. et al. Aqueductal cerebrospinal fluid pulsatility in healthy individuals is affected by impaired cerebral venous outflow. J Magn Reson Imaging 2014; 40 (05) 1215-1222
    CrossrefPubMedGoogle Scholar
  • 32 Schlosser RJ, Wilensky EM, Grady MS, Palmer JN, Kennedy DW, Bolger WE. Cerebrospinal fluid pressure monitoring after repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2004; 130 (04) 443-448
    CrossrefPubMedGoogle Scholar
  • 33 Beaman MH. Community-acquired acute meningitis and encephalitis: a narrative review. Med J Aust 2018; 209 (10) 449-454
    CrossrefPubMedGoogle Scholar
  • 34 van de Beek D, Cabellos C, Dzupova O. et al; ESCMID Study Group for Infections of the Brain (ESGIB). ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect 2016; 22 (Suppl. 03) S37-S62
    CrossrefPubMedGoogle Scholar
  • 35 Edwards C, Leira EC, Gonzalez-Alegre P. Residency training: a failed lumbar puncture is more about obesity than lack of ability. Neurology 2015; 84 (10) e69-e72
    CrossrefPubMedGoogle Scholar
  • 36 Meco C, Oberascher G, Arrer E, Moser G, Albegger K. Beta-trace protein test: new guidelines for the reliable diagnosis of cerebrospinal fluid fistula. Otolaryngol Head Neck Surg 2003; 129 (05) 508-517
    CrossrefPubMedGoogle Scholar
  • 37 Kangsanarak J, Fooanant S, Ruckphaopunt K, Navacharoen N, Teotrakul S. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol 1993; 107 (11) 999-1004
    CrossrefPubMedGoogle Scholar
  • 38 Tebruegge M, Curtis N. Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis. Clin Microbiol Rev 2008; 21 (03) 519-537
    CrossrefPubMedGoogle Scholar
  • 39 Barry B, Delattre J, Vié F, Bedos JP, Géhanno P. Otogenic intracranial infections in adults. Laryngoscope 1999; 109 (03) 483-487
    CrossrefPubMedGoogle Scholar
  • 40 Bell WE. Bacterial meningitis in children. Selected aspects. Pediatr Clin North Am 1992; 39 (04) 651-668
    CrossrefPubMedGoogle Scholar
  • 41 Salazar L, Hasbun R. Cranial Imaging before lumbar puncture in adults with community-acquired meningitis: clinical utility and adherence to the Infectious Diseases Society of America Guidelines. Clin Infect Dis 2017; 64 (12) 1657-1662
    CrossrefPubMedGoogle Scholar
  • 42 McGill F, Heyderman RS, Michael BD. et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 2016; 72 (04) 405-438
    CrossrefPubMedGoogle Scholar
  • 43 Bowles C, Gibson D. Bacterial meningitis: CT for clinically occult sinogenic or otogenic sources. 2015, Abstract Prize, British Society of Head and Neck Meeting, July 2015
    PubMedGoogle Scholar
  • 44 Lloyd KM, DelGaudio JM, Hudgins PA. Imaging of skull base cerebrospinal fluid leaks in adults. Radiology 2008; 248 (03) 725-736
    CrossrefPubMedGoogle Scholar
  • 45 Stone JA, Castillo M, Neelon B, Mukherji SK. Evaluation of CSF leaks: high-resolution CT compared with contrast-enhanced CT and radionuclide cisternography. AJNR Am J Neuroradiol 1999; 20 (04) 706-712
    PubMedGoogle Scholar
  • 46 Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRx 2005; 2 (02) 324-332
    CrossrefPubMedGoogle Scholar
  • 47 Laulajainen Hongisto A, Aarnisalo AA, Lempinen L. et al. Otogenic intracranial abscesses, our experience over the last four decades. J Int Adv Otol 2017; 13 (01) 40-46
    CrossrefPubMedGoogle Scholar
  • 48 Luntz M, Bartal K, Brodsky A, Shihada R. Acute mastoiditis: the role of imaging for identifying intracranial complications. Laryngoscope 2012; 122 (12) 2813-2817
    CrossrefPubMedGoogle Scholar
  • 49 Ibrahim SI, Cheang PP, Nunez DA. Incidence of meningitis secondary to suppurative otitis media in adults. J Laryngol Otol 2010; 124 (11) 1158-1161
    CrossrefPubMedGoogle Scholar