Endonasal Ethmoidectomy and Bifrontal Craniotomy with Craniofacial Approach for Resection of Frontoethmoidal Osteoma Causing Tension Pneumocephalus

ABSTRACT

Tension pneumocephalus is an unusual, potentially life-threatening complication of frontal fossa tumors. We present an uncommon case of a frontoethmoidal osteoma causing a tension pneumocephalus and neurological deterioration prompting a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach for resection. A 68-year-old man presented with a 1-week history of worsening headache, slowness of speech, and increasing confusion. Standard computed tomography scan revealed a marked tension pneumocephalus with ventricular air and 1-cm midline shift to the right. Further studies showed a calcified left ethmoid mass and a left anterior cranial-base defect. A team composed of neurosurgery and otolaryngology performed a combined endonasal ethmoidectomy and bifrontal craniotomy with craniofacial approach to resect a large frontoethmoid bony tumor. No abscess or mucocele was identified. The skull base defect was repaired with the aid of a transnasal endoscopy, a titanium mesh, and a pedunculated pericranial flap. Postoperatively, the pneumocephalus and the patient's symptoms completely resolved. Pathology was consistent with a benign osteoma. This is an uncommon case of a frontoethmoidal osteoma associated with tension pneumocephalus. Recognition of this entity and timely diagnosis and treatment, consisting of an endonasal ethmoidectomy and a bifrontal craniotomy with craniofacial approach, may prevent potential life-threatening complications.

Bifrontal craniotomy - craniofacial - endonasal ethmoidectomy - frontoethmoidal osteoma - tension pneumocephalus

REFERENCES

• 1 Carmody T E. Osteoma of the nasal accessory sinuses.  Ann Otol Rhinol Laryngol. 1935;  44 626-643
• 2 Childrey J H. Osteoma of the sinuses, the frontal and the sphenoid bone: report of fifteen cases.  Arch Otolaryngol. 1939;  30 63-72
• 3 Bartlett J R. Intracranial neurological complications of frontal and ethmoidal osteomas.  Br J Surg. 1971;  58 607-613
• 4 Boysen M. Osteomas of the paranasal sinuses.  J Otolaryngol. 1978;  7 366-370
• 5 Summers L E, Mascott C R, Tompkins J R, Richardson D E. Frontal sinus osteoma associated with cerebral abscess formation: a case report.  Surg Neurol. 2001;  55 235-239
• 6 Teed R W. Primary osteoma of the frontal sinus.  Arch Otolaryngol. 1941;  33 255-292
• 7 Samy L L, Mostafa H. Osteomata of the nose and paranasal sinuses with a report of twenty one cases.  J Laryngol Otol. 1971;  85 449-469
• 8 Arseni C, Chitescu M, Cioloca C. Intracerebral mucocele.  Neurochirurgia (Stuttg). 1973;  16 50-54
• 9 Hardy J M, Montgomery W W. Osteoplastic frontal sinusotomy: an analysis of 250 operations.  Ann Otol Rhinol Laryngol. 1976;  85 523-532
• 10 Diaz F, Latchow R, Duvall 3rd A J, Quick C A, Erickson D L. Mucoceles with intracranial and extracranial extensions. Report of two cases.  J Neurosurg. 1978;  48 284-288
• 11 Close L G, O'Conner W E. Sphenoethmoidal mucoceles with intracranial extension.  Otolaryngol Head Neck Surg. 1983;  91 350-357
• 12 Pompili A, Mastrostefano R, Caroli F et al.. Mucocele of neurosurgical interest: clinical considerations on five cases.  Acta Neurochir (Wien). 1990;  102 114-121
• 13 Young W F, Rosenwasser R H. Intracranial extension of frontoethmoidal sinus mucocele. A delayed complication of chronic sinusitis.  N Y State J Med. 1991;  91 163-164
• 14 Holness R O, Attia E. Osteoma of the frontoethmoidal sinus with secondary brain abscess and intracranial mucocele: case report.  Neurosurgery. 1994;  35 796-797
• 15 Shady J A, Bland L I, Kazee A M, Pilcher W H. Osteoma of the frontoethmoidal sinus with secondary brain abscess and intracranial mucocele: case report.  Neurosurgery. 1994;  34 920-923
• 16 Gezici A R, Okay O, Ergun R, Daglioglu E, Ergungor F. Rare intracranial manifestations of frontal osteomas.  Acta Neurochir (Wien). 2004;  146 393-396
• 17 Wilkes S R, Trautmann J C, DeSanto L W, Campbell R J. Osteoma: an unusual cause of amaurosis fugax.  Mayo Clin Proc. 1979;  54 258-260
• 18 Atallah N, Jay M M. Osteomas of the paranasal sinuses.  J Laryngol Otol. 1981;  95 291-304
• 19 Poser R. Frontal lobe abscess as a complication of frontal sinus osteoma [in German].  Laryngol Rhinol Otol (Stuttg). 1988;  67 136-137
• 20 Smith M E, Calcaterra T C. Frontal sinus osteoma.  Ann Otol Rhinol Laryngol. 1989;  98 896-900
• 21 Ferlito A, Pesavento G, Recher G et al.. Intracranial pneumocephalus (secondary to frontoethmoidal osteoma).  J Laryngol Otol. 1989;  103 634-637
• 22 George J, Merry G S, Jellett L B, Baker J G. Frontal sinus osteoma with complicating intracranial aerocele.  Aust N Z J Surg. 1990;  60 66-68
• 23 Brunori A, Bruni P, Delitala A, Greco R, Chiappetta F. Frontoethmoidal osteoma complicated by intracranial mucocele and hypertensive pneumocephalus: case report.  Neurosurgery. 1995;  36 1237-1238
• 24 Marras L C, Kalaparambath T P, Black S E, Rowed D W. Severe tension pneumocephalus complicating frontal sinus osteoma.  Can J Neurol Sci. 1998;  25 79-81
• 25 Bramley D C, Ghosh S. Tension pneumocephalus attributable to an ethmoid osteoma presenting as a stroke in evolution: an unusual presentation.  Emerg Med J. 2001;  18 317-318
• 26 Johnson D, Tan L. Intraparenchymal tension pneumatocele complicating frontal sinus osteoma: case report.  Neurosurgery. 2002;  50 878-880
• 27 Solero C L, DiMeco F, Sampath P et al.. Combined anterior craniofacial resection for tumors involving the cribriform plate: early postoperative complications and technical considerations.  Neurosurgery. 2000;  47 1296-1305
• 28 Moyer J S, Chepeha D B, Teknos T N. Contemporary skull base reconstruction.  Curr Opin Otolaryngol Head Neck Surg. 2004;  12 294-299
• 29 Sinha U K, Johnson T E, Crockett D, Vadapalli S, Gruen P. Three-layer reconstruction for large defects of the anterior skull base.  Laryngoscope. 2002;  112 424-427
• 30 Badie B, Preston J K, Hartig G K. Use of titanium mesh for reconstruction of large anterior cranial base defects.  J Neurosurg. 2000;  93 711-714