1/10. Spontaneous cerebrospinal fluid otorrhea from a tegmen defect: transmastoid repair with minicraniotomy.Spontaneous cerebrospinal fluid (CSF) otorrhea is a rare condition that presents in 2 clinical categories. In congenital labyrinthine malformations, it leads to bouts of meningitis in a hearing-impaired child. In the adult age group, a spontaneous CSF leak almost always results from a dural and bony defect in the tegmen area. Possible pathogenic mechanisms include progressive sagging and rupture of dura through a congenital tegmen dehiscence and progressive bone erosion by aberrant arachnoid granulations. These patients usually present with a middle ear effusion, resulting in clear discharge after myringotomy with tube insertion. Based on 4 patients with a CSF leak from a tegmen defect, this report reviews the clinical findings and diagnostic approach. The surgical management by a 5-layer closure using a transmastoid approach with minicraniotomy is outlined. This procedure offers a relatively simple and reliable method for repair without the inherent risks of a middle fossa craniotomy.- - - - - - - - - - ranking = 1keywords = meningitis (Clic here for more details about this article) |
2/10. diagnosis and management of spontaneous cerebrospinal fluid-middle ear effusion and otorrhea.OBJECTIVES/HYPOTHESIS: 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. 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. 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. Because tegmen defects may be multiple rather than single, identifying only one defect may not be sufficient for achieving definitive repair. 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. STUDY DESIGN: Retrospective review of nine cases of spontaneous CSF middle ear effusion/otorrhea. RESULTS: The majority of patients presented with symptoms of aural fullness and middle ear effusion. Many developed suspicious clear otorrhea only after insertion of a tympanostomy tube. Two patients had multiple defects in the tegmen and dura, and five patients had meningoencephaloceles confirmed intraoperatively. Five patients underwent combined middle cranial fossa/transmastoid repair. Materials used in repair included temporalis fascia, free muscle graft, Oxycel cotton, calvarial bone, pericranium, bone wax, and fibrin glue. CONCLUSIONS: CSF middle ear effusion/otorrhea can develop in adults without a prior history of meningitis or head trauma or any apparent proximate cause. Although presenting symptoms can be subtle, early suspicion and confirmatory imaging aid in establishing the diagnosis. 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.- - - - - - - - - - ranking = 2keywords = meningitis (Clic here for more details about this article) |
3/10. Carcinomatous meningitis arising from primary nasopharyngeal carcinoma.Carcinomatous meningitis, also known as leptomeningeal metastasis and meningeal carcinomatosis, is the invasion of neoplastic cells into the leptomeninges. Head and neck cancers, especially nasopharyngeal carcinoma, give rise to carcinomatous meningitis very infrequently. In this case report, we present a rare case of carcinomatous meningitis with nasopharyngeal carcinoma as the primary source. In 1987, a 45-year-old white female presented with a few year history of chronic bilateral serous otitis media. She also complained of intermittent diplopia, right facial pain, right-sided headache, and, finally, right facial palsy. The patient was subsequently diagnosed with nasopharyngeal carcinoma by biopsy and treated with radiation as well as chemotherapy. Her neurological symptoms improved, and she did fairly well for several years. However, various neurologic symptoms started to recur, including right facial weakness, right facial numbness in the distribution of all 3 divisions of cranial nerve (CN) V, loss of taste as well as smell, and diplopia. In 1993, magnetic resonance imaging scan of the head revealed recurrence of nasopharyngeal carcinoma with involvement of the ethmoid sinuses as well as extension of the tumor into the frontotemporal leptomeninges. Over the course of the next 3 years, the patient experienced a very gradual decline with involvement of almost all of the CNs (CN I, II, III, V, VI, VII, VIII, IX, X, XII). This case report of carcinomatous meningitis from primary nasopharyngeal carcinoma is one of the few reported in the literature. Although very rare, nasopharyngeal carcinoma can give rise to carcinomatous meningitis, probably by direct invasion of malignant cells. We also review the literature with respect to the diagnosis and treatment of carcinomatosis meningitis.- - - - - - - - - - ranking = 10keywords = meningitis (Clic here for more details about this article) |
4/10. cerebrospinal fluid otorrhea at myringotomy. A meningocele through a defect in the tegmen.Spontaneous cerebrospinal fistulae can simulate secretory otitis media or be discovered at myringotomy, but the diagnosis is frequently made after one or more episodes of meningitis. Congenital perilabyrinthine fistulae are extremely rare, and unlike translabyrinthine fistulae there is usually no sensorineural hearing loss. This is the first reported case of a congenital meningocele through the tegmen in a child. An 11-year-old boy presented with signs and symptoms which mimicked serous otitis media. A cerebrospinal fistula was produced at myringotomy and this was closed surgically via an endaural approach. A CT scan defined a defect in the tegmen tympani anterior to the superior semicircular canal.- - - - - - - - - - ranking = 1keywords = meningitis (Clic here for more details about this article) |
5/10. Tegmental dehiscence and brain herniation into the middle ear cleft.The tegmen tympani may occasionally be breached by herniation of the temporal lobe with or without dural cover. The clinical presentation may be obvious with CSF otorrhoea but less so with apparent middle ear effusion, CSF rhinnorrhoea, conductive hearing loss, recurrent meningitis or intracranial sepsis. diagnosis requires suspicion of the condition, which may be aided by radiological imaging. Surgical repair is to be recommended: various techniques are available but bone enveloped by fascia placed by subtemporal approach is preferred. The features of this problem are highlighted by four cases.- - - - - - - - - - ranking = 1keywords = meningitis (Clic here for more details about this article) |
6/10. subarachnoid space: middle ear pathways and recurrent meningitis.Congenital bony abnormalities of the inner ear may result in a communication between the middle ear and the subarachnoid space. patients with this anomaly often present with recurrent meningitis associated with acute otitis media or with middle ear fluid. This article presents three cases of recurrent meningitis with open middle ear--subarachnoid space connections. The first two cases involve a cerebrospinal fluid leak into the middle ear via the oval window, both patients having a Mondini-type of inner ear deformity. The pathway in the third case opened into the middle ear along the horizontal portion of the facial nerve. Computed tomography (CT) scanning with metrizamide and differential density calculations helped to identify the abnormal pathway and to confirm that the leak has been closed postoperatively. Use of the CT scanner in these cases can be helpful in planning the surgical closure and in postoperative follow-up.- - - - - - - - - - ranking = 6keywords = meningitis (Clic here for more details about this article) |
7/10. Potential complications of unrecognized cerebrospinal fluid leaks secondary to mastoid surgery.Unrecognized cerebrospinal fluid (CSF) drainage from a dural tear created during mastoidectomy rarely occurs, but when it does the consequences may be catastrophic. The potential complications discussed in this article are CSF otorrhea, meningitis, pneumocephalus, and hydrocephalus. The pathophysiology and diagnosis of these complications are individually discussed. The medical management and surgical procedures required to treat such complications are reviewed using a case presentation as an illustration. In addition, a flow sheet detailing the interrelationship between these potential complications and their treatment is outlined.- - - - - - - - - - ranking = 1keywords = meningitis (Clic here for more details about this article) |
8/10. cochlear implants and otitis media: considerations in two cleft palate patients.cochlear implantation is a safe and effective means of rehabilitating profound sensory deafness. The implications of coincident chronic middle ear disease upon the operative procedure and auditory results have received little attention in the literature. We describe two patients, each with congenital cleft lip and palate and secondary chronic otitis media with effusion, who received multichannel cochlear implants following bacterial meningitis. One patient (a three-year-old girl) was implanted in the standard fashion while the other (a 38-year-old-man) underwent middle ear and mastoid obliteration. Our findings suggest that chronic otitis media should not be a deterrent to cochlear implantation.- - - - - - - - - - ranking = 1keywords = meningitis (Clic here for more details about this article) |
9/10. Hypertrophic cranial pachymeningitis with spinal epidural granulomatous lesion.A 67-year-old woman with a one-year history of tinnitus and headache had multiple cranial nerve palsies of V, VII, VIII, IX, X, XI and spastic paraparesis. She also had a secretory otitis media. Gd-DTPA-enhanced magnetic resonance imaging (MRI) revealed hypertrophy of the dura of the posterior fossa and spinal epidural mass which extended from C7 to T10. A biopsy of the epidural mass showed chronic granulomatous change. These lesions were completely cured with administration of antibiotics. We believe this case of double-lesion of hypertrophic cranial pachymeningitis and spinal epidural granulomatous lesion originated from a bacterial infection secondary to the secretory otitis media.- - - - - - - - - - ranking = 5keywords = meningitis (Clic here for more details about this article) |
10/10. Communicating hydrocephalus secondary to diffuse meningeal spread of Wegener's granulomatosis: case report and literature review.OBJECTIVE AND IMPORTANCE: We present a very unusual case of diffuse spread of Wegener's granulomatosis causing hydrocephalus. CLINICAL PRESENTATION: A 53-year-old man presented in 1985 with bilateral middle ear infections requiring myringotomies. During the next 18 months, he went on to develop a left Bell's palsy. The patient then began to develop recurrent occipital headaches along with left sixth and seventh nerve palsies and a green nasal discharge requiring hospitalization. Workup included magnetic resonance imaging showing pronounced enhancement of the tentorium and meninges in the occipital region with normal ventricle size. An x-ray of the chest showed multiple pulmonary nodules. A regimen of prednisone and cyclophosphamide was initiated. The patient did well for 2 years until he again developed middle ear infections and headache. Serial lumbar punctures showed increased pressures. A circulating antineutrophil cytoplasmic antibody was positive. cyclophosphamide was administered, with acetazolamide added for treatment of the elevated intracranial pressure. The patient stabilized for another 2 years but then presented in 1994 with recurrent headache, bilateral papilledema, and mild left arm and right leg weakness. A lumbar puncture was performed with an opening pressure of 52 cm H2O. Computed tomography of the head revealed moderate enlargement of the lateral third and fourth ventricles, consistent with communicating hydrocephalus. INTERVENTION: A right frontal ventriculoperitoneal shunt was placed. A leptomeningeal biopsy performed at the side of catheter placement (far away from any meningeal enhancement revealed by magnetic resonance imaging) showed chronic meningitis and multinucleated giant cells. cyclophosphamide therapy was begun again. The patient has not experienced recurrence of headache, cranial nerve deficits, or papilledema for more than 3 years. CONCLUSION: This is the first reported case of diffuse involvement of the meninges from Wegener's granulomatosis. Fortunately, this patient responded well to shunting and sustained medical management. Although rare, Wegener's granulomatosis should be included in the differential diagnosis of chronic aseptic meningitis, communicating hydrocephalus, and papilledema.- - - - - - - - - - ranking = 2keywords = meningitis (Clic here for more details about this article) |
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