Professional surgery video on Repairing CSF Otorrhea from Middle Fossa

Professional surgery video on Post Traumatic CSF Otorrhea from middle fossa. Surgical procedure performed on a 15-year-old male with a post-traumatic CSF leak following a head injury eight years ago. This patient experienced multiple episodes of meningitis, prompting a thorough investigation.

https://youtu.be/D3kbd8gUS7Y

Professional surgery video on Post Traumatic CSF Otorrhea from middle fossa

I am Dr. Akbar Abbas, and I will walk you through the surgical procedure performed on a 15-year-old male with a post-traumatic cerebrospinal fluid (CSF) leak following a head injury eight years ago. This patient experienced multiple episodes of meningitis, prompting a thorough investigation.

Upon examination of the CT scan and cisternogram, a dural tear and leak in the temporal bone were identified. Two hours prior to commencing the surgery, fluorescein dye was injected into the subarachnoid space.

We observed a defect in the left middle cranial fossa, which was attributed to the head injury and subsequent CSF Otorrhea leakage. To address this issue, a large C-shaped posterior approach was initiated. Cortical mastoidectomy was performed, revealing the venous structures, stapes, and an intact ossicular chain. Facial nerve function and the cisternogram were found to be normal.

Further exploration uncovered a necrotic piece of bone, likely post-traumatic, covering the facial recess. Removal of this bone revealed a leak behind the head of the malleus. An anterior tympanotomy was performed to explore the leak further, with inspection of the posterior fossa, sigmoid area, and facial recess for additional leaks, all of which were absent.

Subsequently, a meticulous exploration around the ossicular chain and the round window was conducted, ruling out potential leaks. The surgery proceeded with drilling and uncovering the dura and the tegmen plate. A small leak was identified just behind the head of the malleus. Preoperatively, the cisternogram had indicated a more significant leak.

Fluorescein injection during surgery revealed a major leak anterior to the head of the malleus, superior to the facial nerve. The leak, measuring over 5 mm, was sealed with multiple layers, including the insertion of temporalis fascia and a superiorly based muscle flap. Cartilage from the tragus was used to secure the fascia and aid in the reconstruction of the external canal.

The necrotic bone from the facial recess was plugged with cartilage and muscle, followed by the placement of additional layers of fascia. The meticulous sealing of the reconstructed eardrum was crucial to avoid interference with the hearing mechanism.

After the placement of gel foam and careful coverage of the facial recess, fibrin glue was poured over the entire reconstruction. Although the decision to retain a lumbar drain for two days was made in consultation with neurosurgery and pediatric colleagues, it's important to note the lack of scientific evidence supporting its routine use in these cases.

The surgery concluded with a thorough examination confirming a tight closure of the leak, and the patient showed no signs of oozing into the attic or mastoid. The use of fibrin glue further secured the reconstruction. An important maneuver involved extending the cortical cavity anteriorly into the root of the zygoma without compromising the ossicular chain (important for hearing).

In summary, the comprehensive surgical approach successfully addressed the CSF leak in this case, with careful consideration given to protecting the hearing mechanism and the absence of scientific evidence supporting postoperative lumbar drain use.

Info: This is an informative and educational video for the benefit of medical students and patients who want to take informed decisions about health. The surgery was performed by Dr Akbar Abbas who is one of the best ENT specialist in Karachi, Pakistan. He specializes in otolaryngology, cochlear implants, ear surgery and is one of the few experts on pituitary and head and neck cancer surgery in Pakistan. Presently serving at Aga Khan University Hospital.

#otolaryngology #repairingcsfotorrhea #surgeryvideo
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