Objective: To present a logical algorithm for management of postoperative cerebrospinal fluid (CSF) leak that occurs after acoustic tumor removal, and to describe a method for eustachian tube resection.
Clinical presentation: We present an algorithm in the form of a flow chart, describe middle fossa craniotomy for eustachian tube resection, and present three cases in which this technique was used.
Technique: For CSF leak, pressure dressing at the wound and bed rest for the patient are advised; lumbar drain is indicated if the leak does not resolve. Occasionally, wound exploration is required. CSF rhinorrhea is treated first with a lumbar drain. If this approach is unsuccessful, the choice of treatment depends on the patient's hearing status. If a patient has no hearing, we perform a blind sac closure of the ear canal and pack the eustachian tube. If a patient has hearing, wound reexploration and lumbar drainage are advised. When conservative and initial surgical procedures for resolving CSF leak fail, we perform a middle fossa craniotomy to identify, divide, and remove a segmental portion of the cartilaginous eustachian tube and then cauterize and occlude both ends.
Conclusion: At centers where surgical removal of acoustic tumors is frequently performed, a logical protocol should be in place for treatment of postoperative CSF leak. The leak location and the patient's hearing status are factors in determining the appropriate treatment method. Middle fossa craniotomy for resection of the eustachian tube is a safe, definitive management option for treatment of recalcitrant CSF rhinorrhea that occurs after acoustic tumor surgery.