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THE SURGICAL MANAGEMENT OF TEMPORAL ENCEPHALOCELE WITH SEVERE MIDDLE EAR INFECTION
Shigehisa Hashimoto, Kuniyuki Takahashi, Yutaka Yamamoto,Sugata Takahashi
Niigata University Faculty of Medicine, Niigata, Japan
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OBJECTIVES: The temporal encephalocele can be repaired via a transmastoid approach, via a middle fossa craniotomy, or by a combined transmastoid/middle fossa approach. We present the surgical management of temporal encephalocele in which it was difficult to improve the middle ear infection.■ METHODS: A 35-year-old woman was diagnosed with chronic otitis media (CT scan in 2000 showed no specific findings), and had a history of purulent otorrhea and the appearance of severe granulation in 2004. 3D-CT scan of the temporal bone showed a bony defect of the tegmen tympani, and extruded region through the bony defect demonstrated a signal continuous with that of intracranial tissue in the sagittal plane MRI. In the pathogenic examination, cortical neural tissue surround the granulation was suspected.
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RESULT: As the middle ear infection was resistant to all preoperative treatment, we had to choose 2 staged and combined approach in order to minimize the surgical risk. In the first stage of operation via the middle fossa, herniated brain tissue were amputated without opening the middle ear cavity. The bone defect can be repaired strongly using a three-layer graft with a temporalis fascia flap extradurally. In the second stage by a transmastoidal approach, amputated brain tissue with granulation filled with the middle ear and mastoid cavity was removed and the bone defect was covered with a periosteal flap at the side of the mastoid cavity. No otorrhea in the middle ear or CSF leakage was found postoperatively.■
CONCLUSION: Each of the three surgical approachs has specific advantage, and generally, the preferred surgical approach is determined by the position, size and the presence of infection. In the present case when infection in the middle ear cannot be improved, a 2 staged and combined operation is one of the surgical options for reducing the intra cranial infection.