Fibrin sealant for control of cerebrospinal fluid otorrhea.

Cerebrospinal fluid (CSF) otorrhea is a potentially common complication of trauma or surgery involving the temporal bone and skull base. Traditional methods of controlling CSF otorrhea include observation with or without subarachnoid lumbar drainage of CSF, reinforcement of the incision, or surgical exploration with operative obliteration of the drainage pathway. In recent years, fibrin sealants have been demonstrated to prevent intraoperative bleeding and fluid leaks in a variety of surgical specialties. Here we describe 2 cases in which application of fibrin sealant to a CSF fistula resulted in closure of the fistula without requiring surgical exploration or repair. We believe that the in-office use of fibrin sealant is a safe and costeffective method to obliterate small CSF leaks arising from the temporal bone. 2. Case 1 A 54-year-old man presented with a 4-month history of gradually decreasing hearing and increasing tinnitus in his right ear. An audiogram revealed a right profound sensorineural hearing loss with a 0% speech discrimination score. Vestibular testing revealed a right vestibulopathy, with caloric responses of the right ear 44% weaker than those of the left ear. Magnetic resonance imaging scan demonstrated an enhancing mass within the right internal auditory canal consistent with an intracanalicular acoustic neuroma. The patient subsequently underwent resection of the acoustic neuroma through a right translabyrinthine approach. The eustachian tube was packed with a plug of muscle and the incus. The operative cavity was obliterated with an abdominal fat graft, and the lateral aspect of the defect was closed with hydroxyapatite cement. On the evening of postoperative day 1, the patient experienced clear drainage from his right ear canal. A computed tomographic scan of the head was obtained, which showed complete obliteration of the mastoid cavity with fat. There was no evidence of airfluid level to suggest CSF leak, and there was no evidence of ventricular dilation. Examination of the ear failed to demonstrate a tympanic membrane (TM) perforation. The drainage was collected for analysis and subsequently tested positive for the presence of β2-transferrin, indicating a CSF leak. On postoperative day 2, the patient was given stool softeners to prevent straining and was placed on strict bed rest, with the head of his bed at 45°. A lumbar drain was placed and set to midbrain with 50 to 80 cc drainage every 8 hours. Cerebrospinal fluid otorrhea persisted despite a functioning lumbar drain. A microscope was brought to the bedside. Again, no obvious perforation in the TM was identified. The source was thought to be through the medial posterior canal wall near the annulus. The TM was covered with a layer of EpiFilm (Medtronic Xomed Inc, Jacksonville, FL), and the external auditory canal (EAC) was filled with 2 to 3 cc of Tisseel fibrin sealant (Baxter Healthcare Corp, Deerfield, IL). No further otorrhea was noted after these interventions. The lumbar drain was kept at midbrain level for 72 hours, clamped for an additional 24 hours, and then discontinued. There was no further evidence of otorrhea and no evidence of fluid accumulation under the wound. The patient was then discharged home and had no evidence of recurrent CSF leak with more than 4 years of follow-up.