![]() Spontaneous intracranial hypotension is usually the result of a CSF leak in the spine. A decrease in CSF volume leads to compensatory dilatation of the vascular spaces, mostly the venous side due to its higher compliance. Intracranial hypotension most commonly results from a CSF leak somewhere along the neuraxis and leads to alterations in the equilibrium between the volumes of intracranial blood, CSF, and brain tissue ( Monro-Kellie hypothesis). Also uncommon, and potentially masking the underlying presence of hypotension is the development of cerebral venous thrombosis, said to occur in approximately 2% of cases of intracranial hypotension 23. Occasionally, presentation is more sinister, with reported cases of decreased level of consciousness and coma 3. Note that if done fluoroscopically, lumbar puncture should be performed in a lateral position to allow for accurate measurement of pressure. ![]() It is confirmed by an opening pressure on lumbar puncture of less than <6 cm H 2O 17. Such would be the case with cerebrospinal fluid (CSF) leak following sinus surgery, pituitary surgery or basal skull fractures. In cases of traumatic or iatrogenic intracranial hypotension, a history of abundant, clear rhinorrhea or otorrhea can sometimes be elicited. The condition often presents as a postural headache which is relieved by lying in a recumbent position, usually within 15-30 minutes 12. Of interest, this is a similar demographic to idiopathic intracranial hypertension, which is believed to be an unrecognised predisposing factor.Įpidemiology of secondary intracranial hypotension is variable and matches that of the underlying cause. Because surgical repair by way of a mastoid approach alone can be inadequate if there are multiple tegmen defects, a middle fossa approach alone, or in combination with a transmastoid approach, should be considered in most cases.Spontaneous intracranial hypotension is typically encountered in middle age (30-50 years of age) and has a predilection for women (F:M = 2:1). Although presenting symptoms can be subtle, early suspicion and confirmatory imaging aid in establishing the diagnosis. Materials used in repair included temporalis fascia, free muscle graft, Oxycel cotton, calvarial bone, pericranium, bone wax, and fibrin glue.ĬSF middle ear effusion/otorrhea can develop in adults without a prior history of meningitis or head trauma or any apparent proximate cause. Five patients underwent combined middle cranial fossa/transmastoid repair. Two patients had multiple defects in the tegmen and dura, and five patients had meningoencephaloceles confirmed intraoperatively. Many developed suspicious clear otorrhea only after insertion of a tympanostomy tube. ![]() The majority of patients presented with symptoms of aural fullness and middle ear effusion. Retrospective review of nine cases of spontaneous CSF middle ear effusion/otorrhea. Data on nine cases of spontaneous CSF leak to the ear in adult patients from four medical centers are presented and analyzed to provide collective information about a disorder that can be difficult to diagnose and manage. Because tegmen defects may be multiple rather than single, identifying only one defect may not be sufficient for achieving definitive repair. A review of relevant medical literature reveals that herniation of the arachnoid membrane through a tegmen defect may be congenital, or CSF leak may occur when dynamic factors (i.e., brain pulsations or increases in intracranial pressure) produce a rent in the arachnoid membrane. Therefore, clues may be lacking that would alert the otolaryngologist that fluid medial to an intact eardrum, or fluid emanating from an eardrum perforation, is likely to be CSF fluid. Spontaneous leak of cerebrospinal fluid (CSF) into the middle ear can occur in adults without a history of temporal bone trauma or fracture, meningitis, or any obvious cause.
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