Abstract
Background
Pneumocephalus is a pathology characterized by air influx into the intracranial 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.
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 . 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 .
The mechanism of formation of pneumocephalus has been explained by the “ball valve mechanism” and the “inverted-soda-bottle effect” . 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) .
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
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 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. 2 A ). 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. 2 B), then fascia lata was laid on top of the adipose tissue ( Fig. 2 C). Fibrin glue was applied to the fascia lata ( Fig. 2 D), 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. Post-operative 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 ).
