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Table of Contents    
LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 6  |  Page : 699-700

Craniocervical pneumatization presenting as cranial nerve IX-XII palsies: Case report and review of the literature


1 Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
2 Department of Radiology Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United State
3 Department of Neurology, The First Xiangya Hospital of Central South University, Changsha, Hunan, China

Date of Submission15-Aug-2014
Date of Decision15-Sep-2014
Date of Acceptance05-Dec-2014
Date of Web Publication16-Jan-2015

Correspondence Address:
Li Yang
Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.149433

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How to cite this article:
Xiao Y, Bai HX, Zhao X, Shu Y, Zou Y, Yang L. Craniocervical pneumatization presenting as cranial nerve IX-XII palsies: Case report and review of the literature. Neurol India 2014;62:699-700

How to cite this URL:
Xiao Y, Bai HX, Zhao X, Shu Y, Zou Y, Yang L. Craniocervical pneumatization presenting as cranial nerve IX-XII palsies: Case report and review of the literature. Neurol India [serial online] 2014 [cited 2019 Sep 17];62:699-700. Available from: http://www.neurologyindia.com/text.asp?2014/62/6/699/149433


Sir,

A previously healthy 68-year-old male presented with dysphagia and slurred speech after a fall. Two weeks prior to presentation, patient suffered a mechanical fall and landed on his tail bone and right elbow. He denied loss of consciousness and hitting his head directly, but heard a "pop" on the right side. Afterwards, he had neck pain and trouble with eating food, specifically closing his mouth. His neurological exam was significant for dysarthria, a palate that deviated to the left, a tongue that deviated to the right [Figure 1]a and subtle right trapezius weakness. The rest of the exam was normal. Computed tomography (CT) and magnetic resonance imaging (MRI) of head and cervical spine revealed extensive craniocervical pneumatization, but no other abnormalities [Figure 1]b-d. The patient was treated with intravenous solumedrol, followed by an extended steroid taper. He required total enteral nutrition and at 1-month, a percutaneous endoscopic gastrostomy tube was placed. At 4 months, there was minimal improvement of the patient's cranial nerve palsies.

Pneumatization of both the skull base and cervical vertebrae is extremely rare. We identified four cases in the English literature that presented with cranial nerve palsies: XII and IX, [1] XII and V, [2] XII alone, [3] and IX alone. [4] All were treated conservatively. Of the two that reported outcome, one resolved completely at 10 days, [3] while the other one had persistent deficits at 4 years after presentation. [1] Pathogenesis of craniocervical pneumatization remains unclear. Theories involve either a developmental anomaly or a relationship to an elevated pressure in the middle and inner ear. [1],[4],[5],[6] This happens in patients with  Eustachian tube More Details dysfunction or those who habitually perform the Valsalva maneuver or engage in repetitive pressure activities such as scuba diving. [5],[6]
Figure 1: Neurological exam was signification for deviation of the tongue to the right (a) Computed tomography (CT) (b, c, axial views) and magnetic resonance imaging (MRI) (d, coronal views) show occipital - temporal and craniocervical pneumatization (arrows)

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In our case, we were unable to demonstrate any skull base or vertebral fractures, but it was felt that the etiology of his cranial nerve dysfunctions was likely his traumatic fall that had resulted in small pathologic fracture of his skull base with a resultant pneumocele. The treatment was conservative because there was no instability involving the craniocervical junction and benefits from aggressive interventions were not considered to outweigh risks. Although the explanations of the findings in the present case remains unclear, this report illustrates that extensive craniocervical pneumatization can cause cranial nerve deficits that may not improve with conservative management alone.


  Acknowledgement Top


This work was supported by the Natural Science Foundation of China (No. 81301988 to L.Y.) and China Ministry of Education Doctoral Program Spot Foundation (20130162120061 to L.Y.).

 
  References Top

1.
Kaiser R, Mehdian H. Permanent twelfth nerve palsy secondary to C0 and C1 fracture in patient with craniocervical pneumatisation. Eur Spine J 2014.  Back to cited text no. 1
    
2.
Sadler DJ, Doyle GJ, Hall K, Crawford PJ. Craniocervical bone pneumatisation. Neuroradiology 1996;38:330-2.  Back to cited text no. 2
    
3.
Renard D, Freitag C, Castelnovo G. Mystery case: Hypoglossal nerve palsy in occipito-temporal pneumatization. Neurology 2012;79:e109-10.  Back to cited text no. 3
    
4.
Quigley AJ, Shannon H. Craniocervical pneumatization. J Radiol Case Rep 2013;7:27-33.  Back to cited text no. 4
    
5.
Moreira B, Som PM. Unexplained extensive skull base and atlas pneumatization: Computed tomographic findings. Arch Otolaryngol Head Neck Surg 2010;136:731-3.  Back to cited text no. 5
    
6.
Littrell LA, Leutmer PH, Lane JI, Driscoll CL. Progressive calvarial and upper cervical pneumatization associated with habitual valsalva maneuver in a 70-year-old man. AJNR Am J Neuroradiol 2004;25:491-3.  Back to cited text no. 6
    


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