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. 2025 Feb 10;86(1):e19-e23.
doi: 10.1055/a-2514-7338. eCollection 2025 Jan.

Keyhole Mini-Craniotomy Middle Fossa Approach for Tegmen Repair: A Case Series and Technical Instruction

Syed M Adil  1 , Tanner J Zachem  1 , Jordan K Hatfield  1 , Jihad Abdelgadir  1 , Kimberly Hoang  2 , Patrick J Codd  1
Affiliations

Keyhole Mini-Craniotomy Middle Fossa Approach for Tegmen Repair: A Case Series and Technical Instruction

Syed M Adil et al. J Neurol Surg Rep. .

Abstract

Background and Importance Tegmen defects associated with cerebrospinal fluid (CSF) leaks are a rare pathology that can result in severe complications if left untreated. There is no universal optimal surgical algorithm for repair, although the most common techniques are the middle fossa craniotomy (traditionally 25 cm 2 in area), the transmastoid approach, or both. Here, we describe successful use of a keyhole mini-craniotomy, only 6 cm 2 in area, without mastoidectomy or days of lumbar drainage. Clinical Presentation Three patients presented with right-sided CSF otorrhea and hearing loss, with varying sizes of tegmen defects and associated encephaloceles. Keyhole craniotomies measuring 3 × 2 cm were used to perform a multilayer repair comprising an intradural collagen dural substitute, extradural fascial graft, extradural collagen dural substitute, fibrin sealant, and sometimes bony reconstruction using partial thickness craniotomy grafting. All patients were discharged on postoperative day 1 or 2, with no recurrence of symptoms at 6 months. Conclusion The keyhole craniotomy approach does not sacrifice the extent of operative access for this pathology. This minimally invasive approach can likely be used more often without need for concomitant mastoidectomy, ultimately enabling shorter hospital stays and more rapid recovery.

Keywords: cerebrospinal fluid leak; keyhole craniotomy; middle cranial fossa approach; mini-craniotomy; minimally invasive; otorrhea; tegmen defect.

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Conflict of interest statement

Conflict of Interest None relevant to discussed techniques. Patrick Codd: Chief Medical Officer of Mente Inc., hold stock and ownership. Chief Scientific Officer of Thexa Technologies Inc., hold stock and ownership. Ownership and consulting revenue through Brainso LLC.

Figures

Fig. 1
Fig. 1
(A, C, E) Preoperative coronal computed tomographies (CTs) demonstrating multiple tegmen defects bilaterally. (B, D, F) Preoperative magnetic resonance imaging (MRI) demonstrating suspected right-sided encephaloceles through tegmen defects.
Fig. 2
Fig. 2
Representative views of intraoperative craniotomy (A), incision at closure (B), and postoperative three-dimensional computed tomography scan showing the right-sided craniotomy (C).
Fig. 3
Fig. 3
Illustration of multilayered tegmen repair with both intradural (DuraGen inlay) and extradural (temporalis fascia graft, DuraGen onlay, fibrin sealant not pictured, and bone graft) components. (A) pre-repair, (B) multilayered tegmen repair, (C) multilayered tegmen repair with split-thickness bone graft placed. Created with BioRender.com.
Fig. 4
Fig. 4
(A) Three tegmen defects identified extradurally, prior to reduction of encephaloceles. (B) Visualization of vein of Labbe via keyhole craniotomy and dural inlay after completion of intradural portion, prior to watertight closure. (C) Fascial graft placed extradurally.
See this image and copyright information in PMC

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