Tegmen tympani defect treatment

There are three surgical approaches for the repair via a middle fossa approach or transmastoid approach or a combined approach. 1) 2) 3). Middle cranial fossa surgery carries the risk of epilepsy while transmastoid repair can result in the loss of hearing.

Corrective surgery employs transmastoid exploration. After any existing meningoceles or meningoencephaloceles have been cauterized or amputated, small grafts of autogenous fascia or cartilage are used to plug defects found. The area is covered with temporalis fascia graft, reinforced by a pedicled muscle-fascia graft and, if needed to obliterate the mastoid cavity, a free graft of subcutaneous abdominal adipose tissue 4).

The exposure does not need to extend medial to the arcuate eminence and requires less retraction of the temporal lobe.

Intraoperatively, the retained CSF within the subarachnoid space provided a protective cushion for the undersurface of the temporal lobe and allowed for the maintenance of fullness of the temporal lobe dura. The fullness of the temporal lobe was found to aid in tightly sealing the tegmen tympani defect. However, the option of lumbar CSF drainage may lessen the degree of temporal lobe retraction and is utilized very effectively in MCF approaches. Careful elevation of the dura from a posterior-to-anterior direction and complete avoidance of bipolar cautery on the MCF floor are essential to preserve facial nerve function 5).

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Bento RF, Pádua FG. Tegmen tympani cerebrospinal fluid leak repair. Acta Otolaryngol. 2004;124:443–448
Schuknecht HF. [Spontaneous cerebrospinal fluid fistula in the tegmen tympani]. HNO. 1994 May;42(5):288-93. German. PubMed PMID: 8050917.
Tanriover N Sanus G Z Ulu M O et al. Middle fossa approach: microsurgical anatomy and surgical technique from the neurosurgical perspective Surg Neurol 2009. 71586–596.596, discussion 596
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