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Spontaneous otogenic posterior fossa pneumocephalus
Otolaryngology–Head and Neck Surgery (2010) 143, 593-594
CASE REPORT
Spontaneous otogenic posterior fossa pneumocephalus George Wanna, MD, Jadrien A. Young, MD, Erik Swanson, MD, and David Haynes, MD, Nashville, TN No sponsorships or competing interests have been disclosed for this article.
F
ew cases of spontaneous pneumocephalus originating from the temporal bone are reported in the literature. We report a patient who presented to us with a six- to eight-week history of gradual decline in neurologic status. The patient had no past medical history that would put her at risk for the development of pneumocephalus; however, computerized tomography (CT) of the head revealed a 5- by 3-cm collection of air in the right posterior fossa with an appreciable dehiscence of bone superior to the vestibular aqueduct. The patient underwent transmastoid retrolabyrinthine approach to the cerebellopontine angle (CPA) to allow for release of this pneumatocele. The patient subsequently demonstrated improvement in neurologic status, and postoperative CT revealed near complete resolution of pneumocephalus.
Case Report A 74-year-old female presented to our medical center from an outside medical facility with gradual decline in neurologic status over a period of six to eight weeks. Review of the patient’s past medical history was negative for head trauma, prior neurosurgical or otologic procedures, neoplasms of the skull base, or chronic infections of the middle ear or mastoid. Secondary to the presence of a pacemaker, magnetic resonance imaging was contraindicated; therefore, CT of the head was obtained and revealed a 5- by 3-cm pneumatocele in the area of the posterior fossa. Imaging showed evidence of compression of the right middle cerebellar peduncle and posterior right upper pons with associated hydrocephalus (Fig 1). The mastoid appeared to be hyperpneumatized, and a small bony dehiscence was identified in the right posterior mastoid air cells just superior to the vestibular aqueduct (Fig 1). The patient subsequently underwent transmastoid retrolabyrinthine approach to the CPA to decompress the area of pneumocephalus. The bone overlying the posterior fossa dura between the sigmoid sinus and the posterior and horizontal semicircular canals
Figure 1 Preoperative CT of the temporal bone showing mastoid defect superior to vestibular aqueduct on the right.
was removed. With removal of this bone, the posterior fossa dura ballooned out laterally. No sign of infection or mass was evident, but the dura in this area was appreciably atrophic. The operative field was then filled with saline and the dura incised; release of air was demonstrated. The dural and mastoid defect created for decompression was repaired with a combination of temporalis muscle, bone paste, fascia, abdominal fat, and fibrin sealant (TISSEEL; Baxter Healthcare, Westlake Village, CA). Head CT on postoperative day one showed near complete resolution of pneumocephalus (Fig 2). By postoperative day two, the patient had near resolution of her aphasia and was speaking in full sentences. The present study was approved by the Vanderbilt University Institutional Review Board.
Discussion Chiari has widely been credited with the description of pneumocephalus in 1884. The first account of traumatic
Received February 1, 2010; revised April 26, 2010; accepted May 3, 2010.
0194-5998/$36.00 © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2010.05.003
594
Otolaryngology–Head and Neck Surgery, Vol 143, No 4, October 2010 middle ear. Therefore, it is likely that pneumocephalus developed in this patient from smaller, repetitive changes over many years. In conclusion, spontaneous pneumocephalus from an otogenic source is a rare entity, and a correct diagnosis relies on a detailed history, attention to clinical presentation, and appropriate imaging. The goals of surgery include decompression of the pneumatocele and definitive closure of the mastoid defect. The case that we present illustrates dramatic improvement after decompression. It is too early in this patient’s clinical course to comment on evidence of recurrence.
Author Information From Vanderbilt University Medical Center, Department of Otolaryngology, Nashville, TN. Corresponding author: Jadrien A. Young, MD, Vanderbilt University Medical Center, Department of Otolaryngology, 7209 Medical Center EastSouth Tower, 1215 21st Ave. South, Nashville, TN 37232-8605. E-mail address: [email protected].
Figure 2 Postoperative CT of the head showing near complete resolution of pneumocephalus on the right.
pneumocephalus from an otogenic source was described by Duken in 1915.1 Since that time, acquired otogenic pneumocephalus has commonly been reported resulting from trauma, neoplasms, ear infections, and skull base surgery.2-4 By contrast, spontaneous otogenic pneumcephalus is a rare entity. Only approximately 10 cases have been reported in the literature since Jelsma’s first description in 1954.5 Two mechanisms behind the evolution of a spontaneous otogenic pneumocephalus have been proposed. The “ball valve” mechanism describes the collection of intracranial air following the creation of high pressure in the pneumatized temporal bone related to the repeated cerebrospinal fluid (CSF) pulsations, swallowing, straining, or Vasalva maneuver. It has been proposed that when hydrostatic pressure is pulsatile in nature, it is capable of bone erosion during the course of many years. The second proposed mechanism requires a continuous CSF leak, which results in the development of negative intracranial pressure. No CSF was encountered with decompression of our patient’s pneumatocele, and there was no history given for a distinct event that would cause pressure changes in the
Author Contributions George Wanna, data collection/analysis, writing; Jadrien A. Young, data collection/analysis, writing; Erik Swanson, data collection/analysis, writing; David Haynes, data collection/analysis.
Disclosures Competing interests: None. Sponsorships: None.
References 1. Vallejo LA, Gil-Carcedo LM, Borras JM, et al. Spontaneous pneumocephalus of otogenic origin. Otolaryngol Head Neck Surg 1999;121: 662–5. 2. Rappaport JM, Attia EL. Pneumocephalus in frontal sinus osteoma: a case report. J Otolaryngol 1994;23:430 – 6. 3. Brunori A, Bruni P, Delitala A, et al. Frontoethmoidal osteoma complicated by intracranial mucocele and hypertensive pneumocephalus: case report. Neurosurgery 1995;36:1237– 8. 4. Clevens RA, Marentette LJ, Esclamado RM, et al. Incidence and management of tension pneumocephalus after anterior craniofacial resection: case reports and review of the literature. Otolaryngol Head Neck Surg 1999;120:579 – 83. 5. Niklaus K, Hatem A, Hans-Heinrich J, et al. Spontaneous otogenic intracerebral pneumocephalus: case report and review of the literature. Eur Arch Otorhinolaryngol 2005;262:135– 8.
CASE REPORT
Spontaneous otogenic posterior fossa pneumocephalus George Wanna, MD, Jadrien A. Young, MD, Erik Swanson, MD, and David Haynes, MD, Nashville, TN No sponsorships or competing interests have been disclosed for this article.
F
ew cases of spontaneous pneumocephalus originating from the temporal bone are reported in the literature. We report a patient who presented to us with a six- to eight-week history of gradual decline in neurologic status. The patient had no past medical history that would put her at risk for the development of pneumocephalus; however, computerized tomography (CT) of the head revealed a 5- by 3-cm collection of air in the right posterior fossa with an appreciable dehiscence of bone superior to the vestibular aqueduct. The patient underwent transmastoid retrolabyrinthine approach to the cerebellopontine angle (CPA) to allow for release of this pneumatocele. The patient subsequently demonstrated improvement in neurologic status, and postoperative CT revealed near complete resolution of pneumocephalus.
Case Report A 74-year-old female presented to our medical center from an outside medical facility with gradual decline in neurologic status over a period of six to eight weeks. Review of the patient’s past medical history was negative for head trauma, prior neurosurgical or otologic procedures, neoplasms of the skull base, or chronic infections of the middle ear or mastoid. Secondary to the presence of a pacemaker, magnetic resonance imaging was contraindicated; therefore, CT of the head was obtained and revealed a 5- by 3-cm pneumatocele in the area of the posterior fossa. Imaging showed evidence of compression of the right middle cerebellar peduncle and posterior right upper pons with associated hydrocephalus (Fig 1). The mastoid appeared to be hyperpneumatized, and a small bony dehiscence was identified in the right posterior mastoid air cells just superior to the vestibular aqueduct (Fig 1). The patient subsequently underwent transmastoid retrolabyrinthine approach to the CPA to decompress the area of pneumocephalus. The bone overlying the posterior fossa dura between the sigmoid sinus and the posterior and horizontal semicircular canals
Figure 1 Preoperative CT of the temporal bone showing mastoid defect superior to vestibular aqueduct on the right.
was removed. With removal of this bone, the posterior fossa dura ballooned out laterally. No sign of infection or mass was evident, but the dura in this area was appreciably atrophic. The operative field was then filled with saline and the dura incised; release of air was demonstrated. The dural and mastoid defect created for decompression was repaired with a combination of temporalis muscle, bone paste, fascia, abdominal fat, and fibrin sealant (TISSEEL; Baxter Healthcare, Westlake Village, CA). Head CT on postoperative day one showed near complete resolution of pneumocephalus (Fig 2). By postoperative day two, the patient had near resolution of her aphasia and was speaking in full sentences. The present study was approved by the Vanderbilt University Institutional Review Board.
Discussion Chiari has widely been credited with the description of pneumocephalus in 1884. The first account of traumatic
Received February 1, 2010; revised April 26, 2010; accepted May 3, 2010.
0194-5998/$36.00 © 2010 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2010.05.003
594
Otolaryngology–Head and Neck Surgery, Vol 143, No 4, October 2010 middle ear. Therefore, it is likely that pneumocephalus developed in this patient from smaller, repetitive changes over many years. In conclusion, spontaneous pneumocephalus from an otogenic source is a rare entity, and a correct diagnosis relies on a detailed history, attention to clinical presentation, and appropriate imaging. The goals of surgery include decompression of the pneumatocele and definitive closure of the mastoid defect. The case that we present illustrates dramatic improvement after decompression. It is too early in this patient’s clinical course to comment on evidence of recurrence.
Author Information From Vanderbilt University Medical Center, Department of Otolaryngology, Nashville, TN. Corresponding author: Jadrien A. Young, MD, Vanderbilt University Medical Center, Department of Otolaryngology, 7209 Medical Center EastSouth Tower, 1215 21st Ave. South, Nashville, TN 37232-8605. E-mail address: [email protected].
Figure 2 Postoperative CT of the head showing near complete resolution of pneumocephalus on the right.
pneumocephalus from an otogenic source was described by Duken in 1915.1 Since that time, acquired otogenic pneumocephalus has commonly been reported resulting from trauma, neoplasms, ear infections, and skull base surgery.2-4 By contrast, spontaneous otogenic pneumcephalus is a rare entity. Only approximately 10 cases have been reported in the literature since Jelsma’s first description in 1954.5 Two mechanisms behind the evolution of a spontaneous otogenic pneumocephalus have been proposed. The “ball valve” mechanism describes the collection of intracranial air following the creation of high pressure in the pneumatized temporal bone related to the repeated cerebrospinal fluid (CSF) pulsations, swallowing, straining, or Vasalva maneuver. It has been proposed that when hydrostatic pressure is pulsatile in nature, it is capable of bone erosion during the course of many years. The second proposed mechanism requires a continuous CSF leak, which results in the development of negative intracranial pressure. No CSF was encountered with decompression of our patient’s pneumatocele, and there was no history given for a distinct event that would cause pressure changes in the
Author Contributions George Wanna, data collection/analysis, writing; Jadrien A. Young, data collection/analysis, writing; Erik Swanson, data collection/analysis, writing; David Haynes, data collection/analysis.
Disclosures Competing interests: None. Sponsorships: None.
References 1. Vallejo LA, Gil-Carcedo LM, Borras JM, et al. Spontaneous pneumocephalus of otogenic origin. Otolaryngol Head Neck Surg 1999;121: 662–5. 2. Rappaport JM, Attia EL. Pneumocephalus in frontal sinus osteoma: a case report. J Otolaryngol 1994;23:430 – 6. 3. Brunori A, Bruni P, Delitala A, et al. Frontoethmoidal osteoma complicated by intracranial mucocele and hypertensive pneumocephalus: case report. Neurosurgery 1995;36:1237– 8. 4. Clevens RA, Marentette LJ, Esclamado RM, et al. Incidence and management of tension pneumocephalus after anterior craniofacial resection: case reports and review of the literature. Otolaryngol Head Neck Surg 1999;120:579 – 83. 5. Niklaus K, Hatem A, Hans-Heinrich J, et al. Spontaneous otogenic intracerebral pneumocephalus: case report and review of the literature. Eur Arch Otorhinolaryngol 2005;262:135– 8.