Endoscopic and fluoroscopic-guided closure of the eustachian tube using a biliary cytology brush and liquid embolic agent for a persistent CSF leak after schwannoma resection

Abstract

Vestibular schwannoma is a known cause of progressive sensorineural hearing loss. Treatment options include observation, radiation therapy and surgical resection. Cerebrospinal fluid (CSF) fistula is a known postsurgical complication that can lead to CSF otorrhoea, rhinorrhoea or CSF leakage from the surgical wound. We present a case report of a patient who underwent vestibular schwannoma resection and postoperatively developed CSF rhinorrhoea, which was refractory to multiple attempts at surgical repair. This was successfully treated under endoscopic and fluoroscopic guidance using a biliary cytology brush to disrupt the surface of the eustachian tube followed by injection of n-Butyl cyanoacrylate.

Keywords: ear; interventional radiology; nose and throat/otolaryngology.

Figure 1

Oblique postmyelogram CT demonstrates contrast tracking from the intracranial subarachnoid space through the right eustachian tube (yellow arrow) and layering within the nasopharynx (blue arrow).

Figure 2

(A) Endoscopic image of the remnant eustachian tube (ET; blue arrow). (B) Endoscopic camera image with a curved metal suction canula at the orifice of the remnant ET. (C) Unsubtracted anteroposterior fluoroscopic single-shot image demonstrating the suction canula within the nasal cavity at ET orifice (yellow arrow) and microcatheter within the right eustachian tube (blue arrow). (D) Oblique intraoperative cone-beam CT image demonstrating a curved metal suction canula at the orifice of the right ET and contrast within the remnant eustachian tube (yellow arrow). (E) Oblique intraoperative cone-beam CT image demonstrates glue cast within the right ET (yellow arrow) extending to the skull base. (F) Endoscopic image demonstrates the glue cast adherent to the nasal mucosa at the ET orifice.