Fluoroscopy-Assisted Transnasal Onyx Occlusion of the Eustachian Tube for Lateral Skull Base Cerebrospinal Fluid Leak Repair

Abstract

Objectives To describe transnasal Eustachian tube (ET) occlusion with a liquid embolic solution for lateral skull base cerebrospinal fluid (CSF) leaks.

Design A lateral skull base CSF fistula model was developed by the authors using fresh cadaveric heads. Using a transtympanic needle, regulated pressurized pigmented saline was continuously instilled into the middle ear space and visualized endoscopically in the nasopharynx. An angioembolization catheter was then placed through the cartilaginous ET orifice just medial to the bony ET. Under endoscopic and fluoroscopic guidance, a column of liquid embolic agent was deployed into the bony ET segment up to the middle ear space.

Setting Tertiary care academic center.

Participants Cadaveric specimens.

Main Outcome Measures Cessation of CSF flow after occlusion at supraphysiologic pressures.

Results In two cadavers, a CSF fistula model was developed and endoscopic visualization of irrigant flow into the nasopharynx was confirmed. Fluoroscopy provided adequate anatomic views of the ET and middle ear, in addition to dynamic views of embolization. Cessation of flow after occlusion was successfully achieved with pressures up to 25 mm Hg, which exceeds normal physiological intracranial pressure.

Conclusion Eustachian tube occlusion with a liquid embolic solution is feasible in a novel cadaveric CSF leak model. In the future, this relatively short, straightforward procedure may become an outpatient alternative to manage intermittent or low-flow CSF fistulae following lateral skull base surgery.

Keywords

cerebrospinal fluid leak - vestibular schwannoma - onyx - fluoroscopy - lateral skull base surgery

Institutional Review Board Approval

Not applicable (cadaver study).

Off-Label Use

Onyx 18 LES (Medtronic; Minneapolis, MN, United States) is not FDA approved for the indications discussed in this study.

Note

This manuscript was presented in part as a poster at the Combined Otolaryngology Spring Meeting (COSM), American Neurotology Society (ANS), San Diego, CA, 2017. This material has not been previously published in part or whole, and is not currently under consideration for publication elsewhere.

• References

• 1 Jacob JT, Pollock BE, Carlson ML, Driscoll CL, Link MJ. Stereotactic radiosurgery in the management of vestibular schwannoma and glomus jugulare: indications, techniques, and results. Otolaryngol Clin North Am 2015; 48 (03) 515-526
• 2 Selesnick SH, Liu JC, Jen A, Newman J. The incidence of cerebrospinal fluid leak after vestibular schwannoma surgery. Otol Neurotol 2004; 25 (03) 387-393
• 3 Allen KP, Isaacson B, Kutz JW, Purcell PL, Roland PS. The association of meningitis with postoperative cerebrospinal fluid fistula. J Neurol Surg B Skull Base 2012; 73 (06) 401-404
• 4 Ajalloveyan M, Doust B, Atlas MD, Fagan PA. Pneumocephalus after acoustic neuroma surgery. Am J Otol 1998; 19 (06) 824-827
• 5 Hamilton JW, Foy PM, Lesser TH. Subtotal petrosectomy in the treatment of cerebrospinal fluid fistulae of the lateral skull base. Br J Neurosurg 1997; 11 (06) 496-500
• 6 Allen KP, Isaacson B, Purcell P, Kutz Jr JW, Roland PS. Lumbar subarachnoid drainage in cerebrospinal fluid leaks after lateral skull base surgery. Otol Neurotol 2011; 32 (09) 1522-1524
• 7 Kwartler JA, Schulder M, Baredes S, Chandrasekhar SS. Endoscopic closure of the eustachian tube for repair of cerebrospinal fluid leak. Am J Otol 1996; 17 (03) 470-472
• 8 Orlandi RR, Shelton C. Endoscopic closure of the eustachian tube. Am J Rhinol 2004; 18 (06) 363-365
• 9 Lemonnier LA, Tessema B, Kuperan AB. , et al. Managing cerebrospinal fluid rhinorrhea after lateral skull base surgery via endoscopic endonasal eustachian tube closure. Am J Rhinol Allergy 2015; 29: 207-10
• 10 Saim L, McKenna MJ, Nadol Jr JB. Tubal and tympanic openings of the peritubal cells: implications for cerebrospinal fluid otorhinorrhea. Am J Otol 1996; 17 (02) 335-339
• 11 Cavallo LM, Solari D, Somma T, Savic D, Cappabianca P. The awake endoscope-guided sealant technique with fibrin glue in the treatment of postoperative cerebrospinal fluid leak after extended transsphenoidal surgery: technical note. World Neurosurg 2014; 82 (3–4): e479-e485
• 12 Elhammady MS, Wolfe SQ, Ashour R. , et al. Safety and efficacy of vascular tumor embolization using Onyx: is angiographic devascularization sufficient?. J Neurosurg 2010; 112 (05) 1039-1045
• 13 Li C, Yang X, Li Y, Jiang C, Wu Z. Endovascular treatment of intracranial dural arteriovenous fistulas presenting with intracranial hemorrhage in 46 consecutive patients: with emphasis on transarterial embolization with Onyx. Clin Neuroradiol 2016; 26 (03) 301-308
• 14 Natarajan SK, Ghodke B, Kim LJ, Hallam DK, Britz GW, Sekhar LN. Multimodality treatment of intracranial dural arteriovenous fistulas in the Onyx era: a single center experience. World Neurosurg 2010; 73 (04) 365-379