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|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 6 | Page : 694-695
Frontal sinus osteoma with pneumocephalus and progressive hemiparesis
Bhaskar Kendre1, Chandrashekhar Deopujari1, Vikram Karmarkar1, Sonali Shah2
1 Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
2 Department of Radiology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
|Date of Submission||01-Nov-2013|
|Date of Decision||08-Nov-2013|
|Date of Acceptance||05-Dec-2013|
|Date of Web Publication||20-Jan-2014|
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kendre B, Deopujari C, Karmarkar V, Shah S. Frontal sinus osteoma with pneumocephalus and progressive hemiparesis. Neurol India 2013;61:694-5
Osteomas of paranasal sinuses are common benign tumors and are diagnosed incidentally. Osteomas presenting as pneumocephalus and hemiparesis is rare, hence this letter.
A 42-year-old male had one episode of generalized tonic clonic seizure in 2001. He had a history of road traffic accident 10 years back. Cranial computed tomography (CT) done in 2001 had shown an osseous lesion of left frontal sinus, which was suspected to be healed fracture [Figure 1]. He was started on antiepileptic medication considering post traumatic epilepsy and the seizures were controlled. In 2003 and 2004, he again had seizures. Magnetic resonance imaging (MRI) done in this period showed persistence of the osseous lesion with no parenchymal abnormality. He was asymptomatic until 2012 when he started developing intermittent right sided weakness. Repeat brain CT done in 2012 [Figure 2] showed the left frontal osseous lesion with intracranial extension and pneumocephalus. As there was no mass effect he was treated conservatively. However his right sided weakness progressed rapidly in the next 2 months and he developed right foot drop. Repeat imaging CT [Figure 3] and MRI [Figure 4] showed the left frontal osteoma with pneumocephalus from the apex of the lesion extending into left frontal lobe, causing a mass effect. The pneumocephalus had increased significantly compared with the previous CT scan. Contrast MRI did not show any other parenchymal pathology.
|Figure 1: Plain computed tomography brain showing left frontal osseous lesion without any pneumocephalus|
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|Figure 2: Plain computed tomography brain showing left frontal osseous lesion with pneumocephalus|
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|Figure 3: Computed tomography brain showing left frontal sinus osseous lesion with subarachnoidal pneumocephalus|
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|Figure 4: Magnetic resonance imaging brain with contrast: Left frontal osseous lesion with pneumocephalus going subarachnoidal in left frontal lobe causing mass effect|
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To relieve the mass effect bifrontal craniotomy was considered. At operation it was noted that the bony tumor had eroded the posterior wall of frontal sinus and dura, with extension into the brain parenchyma. However the outer cortex of sinus was intact [Figure 5]. The bony lesion with the inner wall of the sinus was drilled out completely. After complete removal of the ossifying tumor tissue, the dura was reconstructed with the vascularised pericranial flap. The frontal sinuses were exteriorized. Histopathological examination confirmed the diagnosis of osteoma. The post-operative course was uneventful and CT scans documented progressive resolution of the pneumocephalus. Clinically the hemiparesis improved and he achieved normal power within a week. Follow-up CT [Figure 6] after 3 months showed complete resolution of the pneumocephalus and the patient was asymptomatic without any neurological deficit or seizures.
Frontal sinus osteomas are most common of all paranasal sinus osteomas (80%).  They are benign and slow-growing tumors. Osteomas are usually asymptomatic or may remain silent and grow slowly without causing neurological deficit. However, they may become symptomatic due to direct mass effect or erosion of the posterior sinus wall dura. This may cause CSF leak, meningitis and pneumocephalus. , Pneumocephalus is an uncommon complication of long standing osteomas; however, hemiparesis secondary to such pneumocephalus is a very rare complication. Craniofacial trauma is probably the most common cause of pneumocephalus followed by instrumentation or infection (meningitis) by gas forming organisms  and barotrauma.
This patient presented with a rare case of hemiparesis due to intracranial pneumocephalus caused by erosion of a frontal sinus osteoma. The possible mechanism of pneumocephalus development is due to a defect in the inner wall of frontal sinus and the dura causing one way air flow inside and air getting trapped, like a "one-way ball valve mechanism."  Surgical intervention was curative. Sinus osteomas should be followed for possible intracranial complications. Surgery is worthwhile even in presence of long standing neurological deficit.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]