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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 61
| Issue : 6 | Page : 658-660 |
Vacuum sinus headache: An uncommon presentation of a giant frontal osteoma
Prasad Krishnan1, Manoranjan Jena1, Siddhartha Roy Chowdhury1, Sabyasachi Ojha2
1 Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal, India
2 Department of Neurology, National Neurosciences Centre, Kolkata, West Bengal, India
| Date of Submission | 08-Sep-2013 |
| Date of Decision | 27-Jan-2013 |
| Date of Acceptance | 04-Dec-2013 |
| Date of Web Publication | 20-Jan-2014 |
Correspondence Address:
Prasad Krishnan
Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.125279
How to cite this article:
Krishnan P, Jena M, Chowdhury SR, Ojha S. Vacuum sinus headache: An uncommon presentation of a giant frontal osteoma. Neurol India 2013;61:658-60 |
Sir,
Frontal sinus is the most common site of paranasal sinus osteomas. These tumors are commonly asymptomatic, incidentally diagnosed and are usually not treated surgically. We report a case of giant frontal osteoma with vacuum sinus headache.
A 50-year-old lady had a painless hard, lump on the forehead that had been growing slowly over several years. A diagnosis of calvarial osteoma had been made. Since the patient did not mind the cosmetic dis figurement, no treatment was instituted. However since 6 months before presenting to us she was having intense, bifrontal stabbing headaches after coughing or sneezing which was unresponsive to any kind of treatment. The headaches were particularly severe every time she travelled in an aeroplane (5 times in the last 6 months), occurred during descent but persisted for several hours after landing. It was not associated with any aura, visual problems, tearing, redness of eyes etc., Refraction testing was normal and raised intraocular pressure was ruled out. No history of fever or diurnal variation of headaches was elicited. The headaches were relieved by steam inhalation and occasionally by nasal decongestant drops.
X-rays revealed a radio-opacity in the frontal air sinus on both sides of the midline [Figure 1]. The posterior sinus wall was intact and the part of the frontal sinus not filled by the mass showed air shadows. A computed tomography scan of brain revealed a hyperdense, non-enhancing, well defined mass (3.1 cm × 2.3 cm × 2.5 cm) in the frontal sinus that appeared to go all the way down to the sinus base [Figure 2]. No frontal sinus mucosal thickening was seen. We were able to induce the pain by tickling the inside of her nose with cotton and making her sneeze (6 times out of 10). Based on this a diagnosis of vacuum sinus headache caused by partial blockade of the frontonasal duct was made. | Figure 1: Preoperative X - rays (anterior - posterio and lateral views) showing radio - opaque mass in the frontal sinus on both sides extending to the sinus base
Click here to view |
 | Figure 2: Computed tomography scan showing hyperdense, nonenhancing, well defined mass in the frontal sinus with intact posterior cortical margin. The reconstructed image shows tumor outgrowth onto the forehead. The lesion has gone down all the way to the floor of the sinus where the ostium of the frontonasal duct is located
Click here to view |
The patient underwent removal of the tumor and reconstruction of the defect with obliteration of remaining frontal sinus (after removing the mucosa) using bone cement through a bicoronal skin incision. The tumor was ivory white, hard and was drilled out. The posterior wall of the sinus was removed at places, but the dura was not breached. Post-operative x rays showed cement obliterating the sinus space with reconstruction of the frontal bone curvature [Figure 3]. Post-operatively she has not complained of similar headaches for the last 6 months. | Figure 3: Postoperative X - rays (lateral and anterior - posterio views) showing obliteration of the frontal air sinus, reconstitution of normal frontal bone curvature and bone cement in the erstwhile sinus
Click here to view |
Osteomas, the commonest benign skull tumors, usually arise from the vault of the skull. [1] The frontal sinus is the commonest site of paranasal sinus osteomas (47-80%) [1] and 37% of these originate near the opening of the frontonasal duct. [1] Usually, asymptomatic and incidentally detected, [1],[2] they may occasionally cause complications like sinusitis or mucocele. [1] Rarer complications such as meningitis, lid and cerebral abscess and pneumocephalus have also been described. [1] The incidence of complications is greater with increasing size of the osteoma. [2] Giant osteomas (as in our case) are those whose diameter is greater than 3 cm. [2] Complications in giant osteomas are attributable to local overgrowth with pressure effect on adjacent structures or due to blockade of the outflow duct with retention of secretions. [2]
If the frontonasal duct is transiently blocked, the air inside the sinus may get absorbed and the resulting vacuum like pull on the frontal sinus mucosa may cause pain by stimulating the branches of the trigeminal nerve. [3],[4] This pain can be relieved only if there is equalization of pressure in the sinus to that in the atmosphere. We believe our patient was having headache caused by low pressure in the sinus whose opening was almost totally blocked by the osteoma. The relief she obtained by steam inhalation and nasal decongestant drops was probably due to shrinkage of the mucosa at the narrowed frontonasal duct ostium that allowed ingress of air and equalization of pressure within the sinus to the outside. Other cause of headache in giant frontal sinus osteomas like pressure on the dura or pericranial elevation and irritation were considered unlikely in this case as the posterior cortical margin of the sinus was intact and history of headache started much after the visible growth on the skull began. Our success in provoking pain probably occurred as transient low pressure in the nasal cavity following expulsion of air at high pressure during the act of sneezing would suck air out of the frontonasal duct and create a low pressure situation in the sinus.
This explanation of low sinus pressure is also held to be the cause of airplane associated headache which was first described by in 2004. [3],[4] Such intense pain associated with flying was also present in our patient on multiple occasions. However pathophysiologically as a structural lesion was present, since the pain was present even while not flying and because the pain after flying lasted much longer than 20 min, the criteria of airplane headache as laid forth by Mainardi et al. [4] are not fulfilled. Hence, we venture to call this as vacuum sinus headache.
| » References | |  |
| 1. | Vishwakarma R, Joseph ST, Patel KB, Sharma A. Giant frontal osteoma: Case report with review of literature. Indian J Otolaryngol Head Neck Surg 2011;63:122-6. 
[PUBMED] |
| 2. | Cheng KJ, Wang SQ, Lin L. Giant osteomas of the ethmoid and frontal sinuses: Clinical characteristics and review of the literature. Oncol Lett 2013;5:1724-30.
[PUBMED] |
| 3. | Cherian A, Mathew M, Iype T, Sandeep P, Jabeen A, Ayyappan K. Headache associated with airplane travel: A rare entity. Neurol India 2013;61:164-6.
[PUBMED]  |
| 4. | Mainardi F, Lisotto C, Palestini C, Sarchielli P, Maggioni F, Zanchin G. Headache attributed to airplane travel ("airplane headache"): First Italian case. J Headache Pain 2007;8:196-9.
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[Figure 1], [Figure 2], [Figure 3]
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