No cerebrospinal fluid leaks in translabyrinthine vestibular schwannoma removal: reappraisal of 200 consecutive patients.

OBJECTIVE

The objective of this study was to validate measures taken to reduce the number of cerebrospinal fluid (CSF) leaks after removal of vestibular schwannomas to 0.

STUDY

DESIGN

This study was a retrospective case review.

SETTING

The study was conducted at an otology/neurotology tertiary referral center (Gruppo Otologico, Piacenza, Italy).

PATIENTS: Three hundred thirty-one vestibular schwannoma patients were studied.

INTERVENTIONS: The enlarged translabyrinthine approach (TLA) was used in all cases, with a number of modifications in the last 200 patients. It was extended in 22 patients with blind sac closure of the external meatus, removal of the posterior bony canal wall, and obliteration of the Eustachian tube and middle ear.

MAIN OUTCOME MEASURES: Whether patients had a leak through the wound, the nose (rhinoliquorrhea), or the ear (otoliquorrhea) was assessed.

RESULTS

In an early group, the percentage of CSF leaks was 6.9%. On the basis of the evaluated causes, as time went by, technical modifications evolved. They consisted of 1) the total conservation of the fascioperiosteal flap, 2) obliteration of all petrosal cells possibly communicating with the middle ear, 3) removing the incus in a correct way, 4) closing the attic with periosteum, 5) obliterating the surgical cavity, leaving strips of abdominal fat with their medial ends inside the cerebellopontine angle, 6) suturing the musculo-periosteal layer in a correct way, and 7) fixing the skin flap to the underlying surface. The application of these modifications resulted in a total absence of CSF leaks in 200 consecutive patients thereafter. Also, no cases of meningitis were encountered.

CONCLUSIONS

To our knowledge, this is the first series of 200 consecutive vestibular schwannoma patients operated by means of the enlarged TLA without a single CSF leak. When the appropriate measures are taken, the number of CSF leaks after removing tumors through the enlarged TLA must and can be reduced to 0.