Extensive occipital bone pneumatization presenting as an occipital mass

Craniocervical fractures management in case of craniocervical pneumatization: case report and review of the literature

INTRODUCTION

Extensive craniocervical pneumatization (CCP) refers to an abnormal pneumatization extended from the temporal bone into adjacent bone structures, especially the skull base and the craniocervical junction. The etiology remains controversial; however several studies reported a correlation with recurrent Valsalva maneuvers or Eustachian tube dysfunction. Although some cases requiring surgical treatment have been reported, conservative treatment remains the gold standard. The authors aimed to describe a case of CCP, complicated by a spontaneous fracture of a pneumatized left occipital condyle. Furthermore, they reviewed all previously reported cases of fractures in CCP in order to propose a standardized approach to this pathology.

METHODS

A total of 148 studies were retrieved. Of those, 23 studies (including 26 patients in addition to our case) were included in the review. These studies consisted of case reports or small case series (up to 3 patients).

RESULTS

In 3 patients (11.1%), bone pneumatization involved C0; all remaining patients had both C0 and C1 pneumatization, while in 7 cases (25.9%), an extension to C2 and/or C3 was reported. Radiological follow-up was performed in 20 patients (74.1%), showing in all of the cases either stability (6 patients, 22.2%), improvement, or complete resolution (6 patients, 22.2% vs 8 patients, 29.7%). Two patients underwent surgical intervention.

CONCLUSIONS

This review suggests that fractures secondary to CCP are extremely rare and are associated to a good clinical and radiological outcome with conservative treatment. Ear, nose, and throat (ENT) evaluation is recommended to detect cases who need treatment for a subjacent middle ear disease.

Craniocervical Pneumatization: Estimation of Prevalence and Imaging of Treatment Response

OBJECTIVE

Estimate the prevalence of craniocervical pneumatization (CCP) and describe successful treatment of this condition with clinical and radiologic correlation.

PATIENTS

Individuals with documented CCP on computed tomography (CT).

INTERVENTION(S)

CT scans of the head, temporal bone, face, neck, and cervical spine. Cessation of habitual Valsalva maneuver (VM) and insertion of pressure-equalization (PE) tubes.

MAIN OUTCOME MEASURE

The prevalence of CCP on CT examinations performed during two decades in a large academic healthcare system. Documentation of symptomatic and imaging improvement following treatment of CCP.

RESULTS

Radiology database review identified two cases of CCP out of a total of 636,854 head and neck CT scans (0.00031%) or 43,553 temporal bone CT scans (0.0046%). Both CCP patients were symptomatic (aural fullness, hearing loss, vertigo) and practiced habitual VM. One patient showed decreased CCP 4 months following cessation of VM, whereas the other patient improved symptomatically and demonstrated reversion of CCP to normal bone on magnetic resonance imaging (MRI) within 3 years following PE tube placement.

CONCLUSIONS

Acquired CCP is exceedingly rare and, when successfully treated, reversion to normal bone may accompany symptom resolution.

Craniocervical hyperpneumatization with concurrent pneumorrhachis, pneumomediastinum, and subcutaneous emphysema in a weightlifter

BACKGROUND CONTEXT

Acquired hyperpneumatization of the skull base and upper cervical vertebrae is extremely rare and is thought to occur in patients who habitually perform the Valsalva maneuver or engage in repetitive positive pressure activities such as scuba diving or free diving. Craniocervical hyperpneumatization has been reported to cause intracranial and extracranial pneumatoceles but is not generally considered as a cause of pneumorrhachis (air in the spinal canal). Pneumorrhachis is relatively rare, and usually occurs in a localized form, either in the cervical spine secondary to skull base fractures or in the thoracic spine secondary to pneumomediastinum or pneumothorax. Here, we report a case of extensive pneumorrhachis extending from the skull base to the thoracolumbar junction in association with marked axio-atlanto-occipital hyperpneumatization and pneumomediastinum. This unique constellation of findings likely resulted from complications of the Valsalva maneuver during strenuous exercise.

PURPOSE

To present a unique case of axio-atlanto-occipital hyperpneumatization with concurrent marked cervicothoracic pneumorrhachis, subcutaneous emphysema, and pneumomediastinum and to provide a review of the relevant literature, pathophysiology, and treatment strategies related to hyperpneumatization and pneumorrhachis.

STUDY DESIGN/SETTING

A unique case report from an urban medical center.

PATIENT SAMPLE

A single case.

OUTCOME MEASURES

Imaging findings and clinical history.

METHODS

Imaging data from a picture archiving and communication system and clinical data from an electronic medical record system were analyzed.

RESULTS

A 58-year-old previously healthy man presented with 3 to 4 weeks of neck pain, shoulder pain, and intermittent hand and finger numbness that developed after weightlifting. On physical examination, he had mild hyperreflexia and decreased pinprick sensation within the T5-T8 dermatomes. Initial radiographic and computed tomography (CT) studies demonstrated extensive craniocervical hyperpneumatization involving the occipital bone, clivus, and C1 and C2 vertebral bodies. There was also pneumorrhachis extending throughout the entire cervical and thoracic spine, which caused moderate dural compression. Pneumomediastinum and subcutaneous emphysema were present. Maxillofacial CT showed dehiscent bone involving the dens, atlas, and occipital bone, with adjacent soft-tissue gas and pneumorrhachis. He was managed conservatively and advised to stop performing the Valsalva maneuver during weightlifting. His symptoms resolved, and follow-up imaging showed complete resolution of pneumorrhachis and partial reversal of hyperpneumatization.

CONCLUSIONS

Craniocervical hyperpneumatization is a rare complication of the Valsalva maneuver. Most reported cases have involved only the skull base, or the skull base and C1, and many have been further complicated by microfractures leading to pneumocephalus or extracranial pneumatoceles. We present a unique case of extensive craniocervical hyperpneumatization that extended to the level of C2 and was complicated by microfractures causing severe pneumorrhachis. Concurrent pneumomediastinum in this case may have been an independent complication of the Valsalva maneuver, which could have contributed to pneumorrhachis. Alternatively, pneumomediastinum may have been caused by migration of gas through the neural foramen from the epidural space, driven by positive pressure generated by the one-way valve effect of the Eustachian tube during periods of exertion.

Craniocervical pneumatization

Craniocervical bony pneumatization is a rare finding, with limited numbers of cases reported in the literature. It is thought to be linked to Eustachian tube dysfunction and a ball valve mechanism, and has a link with recurrent Valsalva maneuvers. We report a case of pneumatization of the occiput, atlas (C1) and axis (C2) in a patient with extensive ENT (Ear, Nose and Throat) surgical history who presented following a fall. Plain film, CT and MRI images are presented.

Hyperpneumatization of the skull base: case report

BACKGROUND AND IMPORTANCE

Temporal bone and skull base pneumatization is a naturally occurring process that begins before birth and continues into early adulthood. Occasionally this process surpasses normal limits, resulting in hyperpneumatization, which is usually obvious, but on rare occasions may mimic more aggressive skull base disorders. An awareness of this rare anatomical variant may help clinicians avoid more extensive investigations.

CLINICAL PRESENTATION

We present the case of a 37-year-old man with severe headache and multiple, partially opacified lytic lesions in the skull base noted after minor head trauma. At presentation, a computed tomographic (CT) head scan revealed multiple lucent areas in the skull base after which magnetic resonance imaging (MRI) further suggested the diagnosis of an extensive lytic skull base process associated with a small clival fracture. Needle biopsy revealed nonspecific inflammation. An earlier head CT, not available at the time of admission, demonstrated extensive pneumatized air cells in the basiocciput. During the course of the 2-year follow-up, the originally pneumatized skull base was noted to become permanently opacified with areas of new bone growth.

CONCLUSION

We concluded that the skull base abnormality was an anatomical variant associated with a clival fracture and hemorrhage, which led to opacification of the pneumatized air cells. No specific treatment was offered and symptoms resolved completely. Long-term follow-up CT demonstrated opacification of the skull base. This is one of very few cases in the literature reporting the clinical course of a patient with a hyperpneumatized skull base and the subsequent evolution of the disorder after minor head trauma.

Pneumatization of the skull base due to valsalva maneuver

Objectives : We herewith report the case of a 43-year-old patient who experienced a skull base fracture associated with minimal trauma. The computed tomography scan examination showed unusual extensive pneumatization of the skull base. This patient used to perform repeated Valsalva maneuvers on a daily basis since childhood. Methods : A literature search and analysis of pneumatization mechanisms was performed. Results : Extensive skull base pneumatization has already been reported in patients performing daily Valsalva maneuver. Two pathogenic hypotheses are discussed: the bone cavity expansion through communicating spaces and cavitation secondary to increased intra-osseous pressure transmitted via the venous network with subsequent bone marrow ischemia. Conclusion : Valsalva maneuver may be the cause of an extensive skull base pneumatization. We hypothesize that the Valsalva maneuver may induce bone marrow ischemia that may, if repeated and prolonged, lead to pneumatization.

Atypical extensive extratemporal hyperpneumatization of the skull base including the cervical spine: case report and review of the literature

STUDY DESIGN

Case report and clinical discussion.

OBJECTIVE

To describe a rare case of hyperpneumatization of the skull base including the cervical spine with the atlas bone.

SUMMARY OF BACKGROUND DATA

Initial imaging studies of physically traumatized patients consist of conventional radiographs. An atypical radiolucency is often misdiagnosed as a primary malignancy or a secondary osteolytic metastasis. Further imaging studies may reveal an underlying atypical hyperpneumatization as a very rare benign differential diagnosis. Pathophysiologically, embryological developmental anomalies as well as an elevated pressure to the middle and inner ear are discussed.

METHODS

We present a symptomatic 40-year-old man with conventional radiographs, after computed tomography and magnetic resonance imaging examinations.

RESULTS

Imaging studies reveal an uncommon radiolucency of the skull base including the atlas bone, free air beneath the mastoid bone, stylomastoid foramen, epidural air adjacent to the atlas bone, and surrounding soft-tissue emphysema.

CONCLUSION

Atypical radiolucency may represent a very rare benign hyperpneumatization of the skull base, which may include the craniocervical junction. Because of microfractures of the thinned and consecutive, less stable bones, this also can lead to free air and soft-tissue emphysema, which has not been described previously. Special care should be taken to identify epidural free air because of a possible communication of the epidural space with the external environment. Harmful activities and especially high-speed trauma could result in fractures of the cervical spine due to decreased stability of the hyperpneumatized bones.

Spontaneous otogenic pneumocephalus

The diagnosis and management of spontaneous otogenic pneumocephalus with literature review is described. A young sportsman experienced headache and fluctuating mass in his occiput during increased physical activity. A large extradural intracranial pneumocephalus with corresponding emphysema was imaged on a CT scan. Transmastoid identification and plugging of temporal bone defect solved the problem with complete pneumocephalus and emphysema resorption.

Extensive craniocervical pneumocranium

The authors report the first case of extensive craniocervical pneumocranium causing mass effect, without any associated extradural pneumatocele. The patient presented with frontal headaches and unusual sensations in his left ear. He was found to have large pneumocranium involving his left frontal, temporal, parietal, and occipital bones as well as the atlas. He underwent a craniectomy with replacement of the pneumatized bone with titanium mesh, and mastoidectomy with obliteration of the mastoid air cells. This case is discussed in the context of the literature to date. A review of the literature shows that trauma is not a common cause of pneumocranium, with most cases occurring spontaneously. The authors believe that a combined neurosurgical-otological approach is beneficial in such cases.