- Email: [email protected]
Tension pneumocephalus: an extremely small defect leading to an extremely serious problem
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 74 9–7 5 2
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Tension pneumocephalus: an extremely small defect leading to an extremely serious problem Fadlullah Aksoy, MD, Remzi Dogan, MD⁎, Orhan Ozturan, MD, Selahattin Tuğrul, Yavuz Selim Yıldırım, MD Department of Otorhinolaryngology, Bezmialem Vakif University, Fatih, Istanbul, Turkey
ARTI CLE I NFO
A BS TRACT
Article history:
Background: Pneumocephalus is a pathology characterized by air influx into the intracranial
Received 24 June 2013
region. It may occur after head trauma and rarely after endoscopic sinus surgery. As the amount of air increases, this can cause neurological disorders with a mass effect and this condition is called tension pneumocephalus. Case description: Our case is a 65-year-old woman. Tension pneumocephalus developed 12 h after endoscopic sinus surgery performed for nasal polypectomy. Since tension pneumocephalus developed very rapidly in the patient creating a herniation table, the patient was taken to theater immediately. A burr-hole was drilled into the skull and a small defect in the ethmoid roof was closed with a layered closure technique. Post-operative conservative treatment was applied (bed rest, raising the bed head, meningitis prophylaxis, loop diuretics, abstaining from maneuvers increasing the Valsalva). Discussion: In the literature, it is stated that, in the case of a small defect, spontaneous resolution may be provided with conservative treatment, but as the size of the defect increases, neurological effects will occur more quickly and be more obvious. In our case, a herniation table developed leading to neurological and vital problems in a more rapid and more obvious way than in other tension pneumocephalus cases developing after endoscopic sinus surgery. We consider that this situation is related to a very small defect size. Conclusion: Tension pneumocephalus is a complication rarely seen after endoscopic sinus surgery, but if it is not treated immediately, it may give rise to serious morbidity and mortality concerns. The clinical course developing after tension pneumocephalus may be very serious when very small defects are involved. © 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Endoscopic sinus surgery (ESS) is one of the most frequently applied otorhinolaryngological surgeries at present. After ESS, intracranial complications may occur depending on whether a defect had developed in the skull base during surgery [1]. These complications (CSF rhinorrhea, meningitis, pneumocephalus, tension pneumocephalus, etc.) are quite rare.
Pneumocephalus is a pathology characterized by intrusion of air into the intracranial region. It may develop after neurosurgical interventions or head trauma but may resolve spontaneously and progress asymptomatically. Tension pneumocephalus is a condition in which pneumocephalus progresses gradually, giving a mass effect by creating intracranial hypertension and leading to neurological disorders [2].
⁎ Corresponding author. Medical Faculty, Department of Otorhinolaryngology, Bezmialem Vakif University, Fatih, Istanbul, Turkey. Tel.: + 90 505 7915844; fax: +90 212 533 2326. E-mail address: [email protected] (R. Dogan). 0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2013.07.011
750
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 74 9–7 5 2
Fig. 1 – Postoperative computed tomography (CT) images [(A) axial image, (B) coronal image, (C) sagittal image].
The mechanism of formation of pneumocephalus has been explained by the “ball valve mechanism” [3] and the “invertedsoda-bottle effect” [4]. After injury to the skull base, conditions (coughing, sneezing, vomiting, etc.) inducing positive pressure during the postoperative period cause air to enter into the skull from outside via a defect and lead to tension pneumocephalus. In tension pneumocephalus, clinical presentation is in the form of headache, seizures, agitation, delirium, reflex abnormalities, cognitive abnormalities and brain stem herniation in serious cases (changes in rhythm, hypertension, cranial nerve paralyses, bradycardia and cardiac arrest) [5]. We shall discuss a case with tension pneumocephalus that developed soon after ESS. In our case, tension pneumocephalus developed as a result of a 1 mm skull base defect, unnoticed during surgery, which progressed rapidly and led to herniation findings. In this case, a very small defect created tension pneumocephalus that had a very serious effect on the patient. This condition, the diagnosis and treatment approach will be evaluated with a review of related literature.
2.
with a submerged closed drainage system. The operation continued with endoscopic closure of the defect to stop rhinorrhea and prevent any further air leakage into the cranial cavity. The defect in the skull base was in the medial–medium part of the ethmoid roof. The size of the defect was the same as rope the diameter of nasal packing (about 1 mm) (Fig. 2A). Fascia lata and adipose tissue grafts were taken to close the defect. Adipose tissue was placed into the part where the defect was present (Fig. 2B), then fascia lata was laid on top of the adipose tissue (Fig. 2C). Fibrin glue was applied to the fascia lata (Fig. 2D), and again, adipose tissue and fascia lata were applied. Finally, the edges of the fascia lata were fixed with fibrin glue. This ensured that there was no rhinorrhea. After the intervention, the patient’s bradycardia, arterial tension, respiration rate and anisocoria improved rapidly. Postoperative conservative treatment was applied (bed rest, elevating the head of the bed, meningitis prophylaxis, loop diuretics, abstaining from maneuvers that might increase intracranial pressure). In CT taken on the following day, it was seen that pneumocephalus had regressed to minimal levels (Fig. 3).
Case report
A 53-year-old woman was operated 5 years earlier following a diagnosis of nasal polyp. As a result of recurrence of her complaint, a second operation (revision surgery) was performed by the authors. No complication was reported during surgical operation and extubation. The patient described headache, vomiting, fatigue, and a clear, salty nasal flow for 12 h after the operation. From cranial CT of the patient, there was air filling the frontal region and pushing the brain to the posterior inferior. This appearance was in the form of the “Mount Fuji sign” which is typical of pneumocephalus (Fig. 1). The general state of the patient started to worsen. From a neurological examination, it was seen that she was unconscious, she responded clearly to a painful stimulant, her left pupil was dilated 2 mm more than her right pupil, and her respiration pattern was irregular and superficial. The Glasgow Coma Scale (GCS) score was 4. Vital findings of the patient were: arterial tension 143/92 mmHg; pulse 53/min; respiration rate 13/min; oxygen saturation 94%. The patient was referred to the neurosurgery department and a diagnosis of herniation was established with mass effect caused by tension pneumocephalus. The patient was taken to theater immediately. A right frontal burr-hole was opened to discharge air in the cranial cavity, a drain was placed in the cavity and air was drained
Fig. 2 – Endoscopic appearance of defect in ethmoid roof. (A) Defect on ethmoid roof (indicated by the arrow). (B) Adipose tissue was placed into the defect. (C) Fascia lata was laid onto adipose tissue. (D) Fibrin glue applied on the fascia lata.
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 74 9–7 5 2
Fig. 3 – Pneumocephalus regressed; computed tomography image on the day after surgery.
The postoperative GCS score of the patient was 15 and her vital findings had improved. Her condition was stable and she was discharged 5 days after the operation. In an endoscopic examination in the 2nd week, it was seen that the graft had been successful. The patient has not reported any complaints for 10 months since the operation.
3.
Discussion
Pneumocephalus is a pathology characterized by air influx into the intracranial region. It often occurs as a result of leakage after head trauma (80%) [6]. Apart from head traumas, it is seen after neurosurgical operations, cerebellopontine angle tumors, shunt operations, NO anesthesia, post-barotrauma, post-lumbar puncture and rarely after endoscopic sinus surgery [7–9]. Two mechanisms related to pneumocephalus are discussed in the literature. These are the “ballvalve mechanism” and “inverted-soda-bottle effect” [3,4,10]. Pneumocephalus usually resolves by itself and progresses asymptomatically. However, if the amount of air entering into the skull increases and creates a mass effect, this is called tension pneumocephalus. This is a pathology that is rarely seen but it may induce cerebellum herniation by creating a mass effect [11]. Neurological findings depend on the amount of air, the air leakage rate and its location. They occur when the amount of air exceeds 25 cc, as a result of various compensation mechanisms of the brain [12]. There are a few studies in the literature where tension pneumocephalus develops in patients who underwent ESS surgery for reasons (chronic sinusitis, nasal polyp, etc.) other than mass excision from the skull base (tumor, osteoma, etc.) [13–19]. In the literature, 3 mm is the smallest defect reported [13]. In our case, the defect was 1 mm. In the literature, it was stated that pneumocephalus heals spontaneously with conservative treatment in patients with small defects [13]. Although our case had a smaller defect than those in studies stating the defect size, tension pneumocephalus developed rapidly and it caused herniation symptoms
751
in the patient. It was stated in the literature that sub-acute or unexpected onset of symptoms depends on the size of the defect and as size increases, neurological symptoms will occur more quickly [2,20]. But, in our case, although the defect was very small (1 mm), neurological symptoms emerged within hours and progressed up to herniation table. This condition is a new finding showing that small defects may cause serious neurological problems. In patients with pneumocephalus, the first line of treatment is conservative. In this treatment, the bed head is elevated, and it is requested that the patient remains still and abstains from maneuvers that will cause an increase in intrasinus pressure (sneezing, coughing, Valsalva, etc.). Wide spectrum antibiotic therapy is started because of the risk of meningitis. After this treatment, pneumocephalus undergoes resolution in some patients and recovery may be possible. However, if findings of tension pneumocephalus emerge, this is an indication for immediate surgery. A burrhole should be opened and the defect in the skull base should be closed as soon as possible [17]. In our case, since there was an indication for emergency surgery, a burr-hole was opened and the defect was closed using a layered technique as described in the literature [21].
4.
Conclusion
In our case, a herniation table developed after endoscopic sinus surgery leading to neurological and vital problems in a more rapid and more obvious way than in other tension pneumocephalus cases, and we consider that this situation is related to the very small defect size.
REFERENCES
[1] Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 2013;4:37. [2] Dandy WE. Pneumocephalus (intracranial pneumatocele or aerocele). Arch Surg 1926;12:949–82. [3] Horowitz M. Intracranial pneumocele. An unusual complication following mastoid surgery. J Laryngol Otol 1964;78:128–34. [4] Kuncz A, Roos A, Lujber L, et al. Traumatic prepontine tension pneumocephalus: case report. Ideggyogy Sz 2004;57:313–5. [5] Sadler DJ, Doyle GJ, Hall K, et al. Craniocervical bone pneumatisation. Neuroradiology 1996;38:330–2. [6] Toung TJK, McPherson RW, Ahn H, et al. Pneumocephalus: effects of patient position on the incidence and location of aerocele after posterior fossa and upper cervical cord surgery. Anesth Analg 1986;65:65–70. [7] Lee SH, Koh JS, Bang JS, et al. Extensive tension pneumocephalus caused by spinal tapping in patient with basal skull fracture and pneumothorax. J Korean Neurosurg Soc 2009;45:318–21. [8] Vikram A, Deb AK. Tension pneumocephalus secondary to a dural tear. Appl Radiol 2011;40:37–8. [9] Schnipper D, Spiegel JH. Management of intracranial complications of sinus surgery. Otolaryngol Clin North Am 2004;37:453–72. [10] Simmons J, Luks AM. Tension pneumocephalus: an uncommon cause of altered mental status. J Emerg Med 2013;44:340–3. [11] North JB. On the importance of intracranial air. Br J Surg 1999;34:345–9.
752
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 74 9–7 5 2
[12] DelGaudio JM, Ingley AP. Treatment of pneumocephalus after endoscopic sinus and microscopic skull base surgery. Am J Otolaryngol 2010;31:226–30. [13] Whitmore RG, Bonhomme G, Balcer LJ, et al. Tension pneumocephalus after endoscopic sinus surgery: case report of repair and management in absence ofobvious skull base defect. Ear Nose Throat J 2008;87:96–9. [14] Celevens IIA, Bradford CR, Wolf GT. Tension pneumocephalus after endoscopic sinus surgery. Ann Otot Rhinol Laryngo 1994; IO3:235–7. [15] Davis DH, Laws Jr ER, McDonald Jr T, et al. Intraventricular tension pneumocephalus asa complication of paranasal sinus surgery: case report. Neurosurgery 1981;8:574. [16] Chou S, Ning M, Buonanno F. Focal intraparenchymal tension pneumocephalus. Neurology 2006;67:1485.
[17] Prüss H, Klingebiel R, Endres M. Tension pneumocephalus with diplegia and deterioration of consciousness. Case Rep Neurol 2011;14:48–9. [18] Emmez H, Durdag E, Uslu S, et al. Intracerebral tension pneumocephalus complicating endoscopic sinus surgery: case report. Acta Neurochir (Wien) 2009;151:1001–2. [19] Church CA, Chiu AG, Vaughan WC. Endoscopic repair of large skull base defects after powered sinus surgery. Otolaryngol Head Neck Surg 2003;129:204–9. [20] Burns LA, Dodson HE, Gross CW. Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up. Laryngoscope 1996;106:l080–3. [21] Lanza DC, O'Brien DA, Kennedy DW. Endostopic repair of cerebrospinal fluid tistulae and encephaloceles. Laryngoscope 1996;106:1119–25.
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Tension pneumocephalus: an extremely small defect leading to an extremely serious problem Fadlullah Aksoy, MD, Remzi Dogan, MD⁎, Orhan Ozturan, MD, Selahattin Tuğrul, Yavuz Selim Yıldırım, MD Department of Otorhinolaryngology, Bezmialem Vakif University, Fatih, Istanbul, Turkey
ARTI CLE I NFO
A BS TRACT
Article history:
Background: Pneumocephalus is a pathology characterized by air influx into the intracranial
Received 24 June 2013
region. It may occur after head trauma and rarely after endoscopic sinus surgery. As the amount of air increases, this can cause neurological disorders with a mass effect and this condition is called tension pneumocephalus. Case description: Our case is a 65-year-old woman. Tension pneumocephalus developed 12 h after endoscopic sinus surgery performed for nasal polypectomy. Since tension pneumocephalus developed very rapidly in the patient creating a herniation table, the patient was taken to theater immediately. A burr-hole was drilled into the skull and a small defect in the ethmoid roof was closed with a layered closure technique. Post-operative conservative treatment was applied (bed rest, raising the bed head, meningitis prophylaxis, loop diuretics, abstaining from maneuvers increasing the Valsalva). Discussion: In the literature, it is stated that, in the case of a small defect, spontaneous resolution may be provided with conservative treatment, but as the size of the defect increases, neurological effects will occur more quickly and be more obvious. In our case, a herniation table developed leading to neurological and vital problems in a more rapid and more obvious way than in other tension pneumocephalus cases developing after endoscopic sinus surgery. We consider that this situation is related to a very small defect size. Conclusion: Tension pneumocephalus is a complication rarely seen after endoscopic sinus surgery, but if it is not treated immediately, it may give rise to serious morbidity and mortality concerns. The clinical course developing after tension pneumocephalus may be very serious when very small defects are involved. © 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Endoscopic sinus surgery (ESS) is one of the most frequently applied otorhinolaryngological surgeries at present. After ESS, intracranial complications may occur depending on whether a defect had developed in the skull base during surgery [1]. These complications (CSF rhinorrhea, meningitis, pneumocephalus, tension pneumocephalus, etc.) are quite rare.
Pneumocephalus is a pathology characterized by intrusion of air into the intracranial region. It may develop after neurosurgical interventions or head trauma but may resolve spontaneously and progress asymptomatically. Tension pneumocephalus is a condition in which pneumocephalus progresses gradually, giving a mass effect by creating intracranial hypertension and leading to neurological disorders [2].
⁎ Corresponding author. Medical Faculty, Department of Otorhinolaryngology, Bezmialem Vakif University, Fatih, Istanbul, Turkey. Tel.: + 90 505 7915844; fax: +90 212 533 2326. E-mail address: [email protected] (R. Dogan). 0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2013.07.011
750
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 74 9–7 5 2
Fig. 1 – Postoperative computed tomography (CT) images [(A) axial image, (B) coronal image, (C) sagittal image].
The mechanism of formation of pneumocephalus has been explained by the “ball valve mechanism” [3] and the “invertedsoda-bottle effect” [4]. After injury to the skull base, conditions (coughing, sneezing, vomiting, etc.) inducing positive pressure during the postoperative period cause air to enter into the skull from outside via a defect and lead to tension pneumocephalus. In tension pneumocephalus, clinical presentation is in the form of headache, seizures, agitation, delirium, reflex abnormalities, cognitive abnormalities and brain stem herniation in serious cases (changes in rhythm, hypertension, cranial nerve paralyses, bradycardia and cardiac arrest) [5]. We shall discuss a case with tension pneumocephalus that developed soon after ESS. In our case, tension pneumocephalus developed as a result of a 1 mm skull base defect, unnoticed during surgery, which progressed rapidly and led to herniation findings. In this case, a very small defect created tension pneumocephalus that had a very serious effect on the patient. This condition, the diagnosis and treatment approach will be evaluated with a review of related literature.
2.
with a submerged closed drainage system. The operation continued with endoscopic closure of the defect to stop rhinorrhea and prevent any further air leakage into the cranial cavity. The defect in the skull base was in the medial–medium part of the ethmoid roof. The size of the defect was the same as rope the diameter of nasal packing (about 1 mm) (Fig. 2A). Fascia lata and adipose tissue grafts were taken to close the defect. Adipose tissue was placed into the part where the defect was present (Fig. 2B), then fascia lata was laid on top of the adipose tissue (Fig. 2C). Fibrin glue was applied to the fascia lata (Fig. 2D), and again, adipose tissue and fascia lata were applied. Finally, the edges of the fascia lata were fixed with fibrin glue. This ensured that there was no rhinorrhea. After the intervention, the patient’s bradycardia, arterial tension, respiration rate and anisocoria improved rapidly. Postoperative conservative treatment was applied (bed rest, elevating the head of the bed, meningitis prophylaxis, loop diuretics, abstaining from maneuvers that might increase intracranial pressure). In CT taken on the following day, it was seen that pneumocephalus had regressed to minimal levels (Fig. 3).
Case report
A 53-year-old woman was operated 5 years earlier following a diagnosis of nasal polyp. As a result of recurrence of her complaint, a second operation (revision surgery) was performed by the authors. No complication was reported during surgical operation and extubation. The patient described headache, vomiting, fatigue, and a clear, salty nasal flow for 12 h after the operation. From cranial CT of the patient, there was air filling the frontal region and pushing the brain to the posterior inferior. This appearance was in the form of the “Mount Fuji sign” which is typical of pneumocephalus (Fig. 1). The general state of the patient started to worsen. From a neurological examination, it was seen that she was unconscious, she responded clearly to a painful stimulant, her left pupil was dilated 2 mm more than her right pupil, and her respiration pattern was irregular and superficial. The Glasgow Coma Scale (GCS) score was 4. Vital findings of the patient were: arterial tension 143/92 mmHg; pulse 53/min; respiration rate 13/min; oxygen saturation 94%. The patient was referred to the neurosurgery department and a diagnosis of herniation was established with mass effect caused by tension pneumocephalus. The patient was taken to theater immediately. A right frontal burr-hole was opened to discharge air in the cranial cavity, a drain was placed in the cavity and air was drained
Fig. 2 – Endoscopic appearance of defect in ethmoid roof. (A) Defect on ethmoid roof (indicated by the arrow). (B) Adipose tissue was placed into the defect. (C) Fascia lata was laid onto adipose tissue. (D) Fibrin glue applied on the fascia lata.
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 74 9–7 5 2
Fig. 3 – Pneumocephalus regressed; computed tomography image on the day after surgery.
The postoperative GCS score of the patient was 15 and her vital findings had improved. Her condition was stable and she was discharged 5 days after the operation. In an endoscopic examination in the 2nd week, it was seen that the graft had been successful. The patient has not reported any complaints for 10 months since the operation.
3.
Discussion
Pneumocephalus is a pathology characterized by air influx into the intracranial region. It often occurs as a result of leakage after head trauma (80%) [6]. Apart from head traumas, it is seen after neurosurgical operations, cerebellopontine angle tumors, shunt operations, NO anesthesia, post-barotrauma, post-lumbar puncture and rarely after endoscopic sinus surgery [7–9]. Two mechanisms related to pneumocephalus are discussed in the literature. These are the “ballvalve mechanism” and “inverted-soda-bottle effect” [3,4,10]. Pneumocephalus usually resolves by itself and progresses asymptomatically. However, if the amount of air entering into the skull increases and creates a mass effect, this is called tension pneumocephalus. This is a pathology that is rarely seen but it may induce cerebellum herniation by creating a mass effect [11]. Neurological findings depend on the amount of air, the air leakage rate and its location. They occur when the amount of air exceeds 25 cc, as a result of various compensation mechanisms of the brain [12]. There are a few studies in the literature where tension pneumocephalus develops in patients who underwent ESS surgery for reasons (chronic sinusitis, nasal polyp, etc.) other than mass excision from the skull base (tumor, osteoma, etc.) [13–19]. In the literature, 3 mm is the smallest defect reported [13]. In our case, the defect was 1 mm. In the literature, it was stated that pneumocephalus heals spontaneously with conservative treatment in patients with small defects [13]. Although our case had a smaller defect than those in studies stating the defect size, tension pneumocephalus developed rapidly and it caused herniation symptoms
751
in the patient. It was stated in the literature that sub-acute or unexpected onset of symptoms depends on the size of the defect and as size increases, neurological symptoms will occur more quickly [2,20]. But, in our case, although the defect was very small (1 mm), neurological symptoms emerged within hours and progressed up to herniation table. This condition is a new finding showing that small defects may cause serious neurological problems. In patients with pneumocephalus, the first line of treatment is conservative. In this treatment, the bed head is elevated, and it is requested that the patient remains still and abstains from maneuvers that will cause an increase in intrasinus pressure (sneezing, coughing, Valsalva, etc.). Wide spectrum antibiotic therapy is started because of the risk of meningitis. After this treatment, pneumocephalus undergoes resolution in some patients and recovery may be possible. However, if findings of tension pneumocephalus emerge, this is an indication for immediate surgery. A burrhole should be opened and the defect in the skull base should be closed as soon as possible [17]. In our case, since there was an indication for emergency surgery, a burr-hole was opened and the defect was closed using a layered technique as described in the literature [21].
4.
Conclusion
In our case, a herniation table developed after endoscopic sinus surgery leading to neurological and vital problems in a more rapid and more obvious way than in other tension pneumocephalus cases, and we consider that this situation is related to the very small defect size.
REFERENCES
[1] Solomiichuk VO, Lebed VO, Drizhdov KI. Posttraumatic delayed subdural tension pneumocephalus. Surg Neurol Int 2013;4:37. [2] Dandy WE. Pneumocephalus (intracranial pneumatocele or aerocele). Arch Surg 1926;12:949–82. [3] Horowitz M. Intracranial pneumocele. An unusual complication following mastoid surgery. J Laryngol Otol 1964;78:128–34. [4] Kuncz A, Roos A, Lujber L, et al. Traumatic prepontine tension pneumocephalus: case report. Ideggyogy Sz 2004;57:313–5. [5] Sadler DJ, Doyle GJ, Hall K, et al. Craniocervical bone pneumatisation. Neuroradiology 1996;38:330–2. [6] Toung TJK, McPherson RW, Ahn H, et al. Pneumocephalus: effects of patient position on the incidence and location of aerocele after posterior fossa and upper cervical cord surgery. Anesth Analg 1986;65:65–70. [7] Lee SH, Koh JS, Bang JS, et al. Extensive tension pneumocephalus caused by spinal tapping in patient with basal skull fracture and pneumothorax. J Korean Neurosurg Soc 2009;45:318–21. [8] Vikram A, Deb AK. Tension pneumocephalus secondary to a dural tear. Appl Radiol 2011;40:37–8. [9] Schnipper D, Spiegel JH. Management of intracranial complications of sinus surgery. Otolaryngol Clin North Am 2004;37:453–72. [10] Simmons J, Luks AM. Tension pneumocephalus: an uncommon cause of altered mental status. J Emerg Med 2013;44:340–3. [11] North JB. On the importance of intracranial air. Br J Surg 1999;34:345–9.
752
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 74 9–7 5 2
[12] DelGaudio JM, Ingley AP. Treatment of pneumocephalus after endoscopic sinus and microscopic skull base surgery. Am J Otolaryngol 2010;31:226–30. [13] Whitmore RG, Bonhomme G, Balcer LJ, et al. Tension pneumocephalus after endoscopic sinus surgery: case report of repair and management in absence ofobvious skull base defect. Ear Nose Throat J 2008;87:96–9. [14] Celevens IIA, Bradford CR, Wolf GT. Tension pneumocephalus after endoscopic sinus surgery. Ann Otot Rhinol Laryngo 1994; IO3:235–7. [15] Davis DH, Laws Jr ER, McDonald Jr T, et al. Intraventricular tension pneumocephalus asa complication of paranasal sinus surgery: case report. Neurosurgery 1981;8:574. [16] Chou S, Ning M, Buonanno F. Focal intraparenchymal tension pneumocephalus. Neurology 2006;67:1485.
[17] Prüss H, Klingebiel R, Endres M. Tension pneumocephalus with diplegia and deterioration of consciousness. Case Rep Neurol 2011;14:48–9. [18] Emmez H, Durdag E, Uslu S, et al. Intracerebral tension pneumocephalus complicating endoscopic sinus surgery: case report. Acta Neurochir (Wien) 2009;151:1001–2. [19] Church CA, Chiu AG, Vaughan WC. Endoscopic repair of large skull base defects after powered sinus surgery. Otolaryngol Head Neck Surg 2003;129:204–9. [20] Burns LA, Dodson HE, Gross CW. Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up. Laryngoscope 1996;106:l080–3. [21] Lanza DC, O'Brien DA, Kennedy DW. Endostopic repair of cerebrospinal fluid tistulae and encephaloceles. Laryngoscope 1996;106:1119–25.