An unusual cause for therapy-resistant headache

Introduction We report the case of a patient with subcranial osteomyelitis and lesion of the caudal cranial nerves as a rare complication following biopsy of a Tornwald-cyst.

Case Presentation The 79 year old multimorbid patient complained of severe, persistent left-sided cephalgia. He subsequently developed ipsilateral facial paresis and dysfunction of the caudal cranial nerves. He reported that two months previously a biopsy from a lesion in the nasopharynx had been taken alio loco. The pathological analysis had revealed a Tornwaldt-cyst. The lesion had been found incidentally in a cranial MRI performed to investigate the cause of unexplained B symptoms.

Diagnostics In flexible rhinoscopy the mucosa of the nasopharynx was fibrin-coated paramedially on the left. A CT-scan showed an arrosion of the clivus on the left hand side. After resecting the fibrin-coated mucosa during endoscopy under general anesthesia a duct into the clivus filled with pus was revealed. An MRI showed a pseudo aneurysm of the internal carotid artery on the left hand side. In the further course a colorectal carcinoma was identified as the cause of the initial B symptoms.

Therapy Coilembolisation of the internal carotid artery was performed parallel to intravenous antibiotic therapy in order to avoid a septic rupture of the artery. Furthermore placement of a PEG-tube was necessary because the patient was suffering from dysphagia. These measures successfully prevented further progress of the osteomyelitis.

Conclusion The presence of immunosuppressant comorbidities such as diabetes or unexplained B symptoms raising the risk of infections should be considered when indicating and performing an operation. Such a constellation can make a normally low risk operation have life threatening consequences.

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Publication History

Article published online:
10 June 2020