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Management of large tegmen defects and meningoencephalic herniation following Cholesteatoma surgery

Presenting Author: Mohamed Badr-El-Dine

Published online by Cambridge University Press:  03 June 2016

Mohamed Badr-El-Dine
Mohamed Badr-El-Dine*
Affiliation:
Faculty of Medicine, University of Alexandria, EGYPT
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Abstract

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Learning Objectives:

Objective: The purpose of this presentation is to highlight the importance of tegmen defects that may result following cholesteatoma and mastoid surgery and emphasize the technical details for their reconstruction.

Introduction: Despite marked decline in the incidence of complications of CSOM, life-threatening complications still exist. The presence of thinning or dehiscence of the tegmen tympani or mastoideum is fairly common in CSOM especially after mastoidectomy, but only small portion of patients will demonstrate meningo/encephaloceles and CSF leakage.

Objective: The purpose of this presentation is to highlight the importance of tegmen defects that may result following cholesteatoma and mastoid surgery and emphasize the technical details for their reconstruction.

Methods: Fourteen patients operated for surgical repair of tegmen defects associated with different degrees of meningoencephalic herniation. Surgical approaches: 1) transmastoid; 2) middle cranial fossa; and 3) combination of both approaches. The choice of approach depends on size and site of the defect, hearing level, and surgeon experience. Small tegmen defects can be managed efficiently through the mastoid approach, while large defects require combined MCF and mastoidectomy. Following extradural dissection and encephalocele reduction or resection, we use a multilayer closure for direct repair of the dural and bony cranial base defects. Concave calvarial bone cut from the temporal craniotomy flap provides excellent material for reconstruction without any impingement on ossicular chain.

Results: All patients underwent surgical reconstruction of their tegmen defects without significant intraoperative or postoperative complications. All patients exhibited normal facial function postoperatively. None of our cases required lumbar drain placement.

Conclusion: Combined MCF and mastoidectomy approach proved effective to repair tegmen and dural defects. Surgical repair prevents progression and meningitis. Advantages of this technique are the control of the floor of the MCF and reconstruct large-size bony defects even those located anteriorly without disrupting the ossicular chain.