Management of brain herniation and cerebrospinal fluid leak in revision chronic ear surgery

Objectives/Hypothesis: Brain herniation and cerebrospinal fluid (CSF) leakage into the middle ear and mastoid are rare but described complications of chronic ear disease. This paper will discuss the presentation and management of brain herniation and/or CSF leak encountered in revision chronic ear surgery. Study Design: Retrospective chart review. Methods: Twelve of 1,130 cases of revision chronic ear surgery in which brain herniation or CSF leak was diagnosed were identified and analyzed. Results: Ten (83%) patients' initial diagnosis was tympanic membrane (TM) perforation with cholesteatoma and two (17%) with TM perforation without cholesteatoma. Initial revision procedures included one (8.3%) tympanoplasty with canal-wall-up mastoidectomy maintaining ossicular continuity, two (17%) tympanoplasties with canal-wall-down (CWD) mastoidectomies with ossicular chain reconstruction (OCR), and nine (75%) tympanoplasties with CWD mastoidectomies without OCR. Three (25%) required a second procedure, two (17%) a third, and one (8.3%) a fourth, finally resulting in four (33%) with an ossicular reconstruction and eight (67%) without. Brain herniation and/or CSF leak were repaired by way of transmastoid and middle fossa approaches. Preoperative and postoperative pure-tone average air-bone gaps were statistically similar (33.1 and 28.1 dbHL, respectively; P = .464), Conclusions: Brain herniation and/or CSF leak appear to be rare complications of surgery for revision chronic ear disease. Their management require adherence to the principles of establishing a safe ear with hearing restoration as a secondary goal.