Keyhole Middle Fossa Approach with Titanium Mesh “Gull Wing” Repair for Tegmen Defects

Objective: The optimal surgical strategy for tegmen defect repair remains controversial. Transmastoid approaches theoretically provide a simple approach with a quicker recovery, though more anterior defects may be inaccessible. Higher flow leaks may also be more challenging to manage.[1] The middle fossa craniotomy provides wide access to the entire tegmen. This approach often requires temporal lobe manipulation, lumbar drain placement, and longer recovery.[2] We describe the use of a keyhole middle fossa approach with a simple titanium skull base repair that allows for wide access with no temporal lobe manipulation and does not require lumbar drain placement.

Methods: A retrospective review was performed on 14 consecutive patients with spontaneous CSF otorrhea. Each patient underwent a keyhole (∼1 × 2 cm craniectomy) middle fossa approach, with complete visualization of the posterior middle fossa tegmen region, followed by multilayer dural repair with titanium mesh “gull wing” skull base reconstruction (Figs. 1 and 2).[3] If there was a prior myringotomy, a myringoplasty then performed. Demographic information, including BMI and defect laterality, was recorded. Postoperative measures included operative time, length-of-hospital stay, CSF leak recurrence, and surgical complications (seizures, hemorrhage, aphasia, and infection).

Results: Preoperative patient demographics are seen in Table 1A, operative times and hospital length of stay (LOS) are seen in Table 1B, and postoperative complications are seen in Table 1C. Lumbar drain was placed postoperatively for 1 day in three patients due to fluid egress from myringoplasty site to aid in myringoplasty healing. There were no recurrences over a mean follow-up of 20.3 months (range = 5–48 months).

Conclusion: A minimally invasive keyhole middle fossa approach with a multilayer dural reconstruction including titanium mesh “gull wing” skull base repair provides a quick and effective treatment for a broad spectrum of tegmen defects and meningoencephaloceles. This exposure and reconstruction technique does not require the use of a lumbar drain and results in minimal hospitalization.

No conflict of interest has been declared by the author(s).

• References

• Marchioni D, Bonali M, Alicandri-Ciufelli M, Rubini A, Pavesi G, Presutti L. Combined approach for tegmen defects repair in patients with cerebrospinal fluid otorrhea or herniations: our experience. J Neurol Surg B Skull Base 2014; 75 (04) 279-287
• Perez E, Carlton D, Alfarano M, Smouha E. Transmastoid repair of spontaneous cerebrospinal fluid leaks. J Neurol Surg B Skull Base 2018; 79 (05) 451-457
• Wong RH, Agazzi S, van Loveren H. “Inverted gull wing” dural closure and middle fossa floor reconstruction after transzygomatic infratemporal fossa approach. World Neurosurg 2016; 89: 280-284