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|LETTERS TO EDITOR
|Year : 2018 | Volume
| Issue : 2 | Page : 551-553
Occipital condyle syndrome due to tuberculosis: An uncommon cause unearthed by an unconventional approach
Prasad Krishnan1, Sayan Das2, Pravin Salunke3
1 Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, Kolkata, India
2 Department of Radio-diagnosis, Peerless Hospital and B K Roy Research Centre, Kolkata, West Bengal, India
3 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||15-Mar-2018|
Dr. Pravin Salunke
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnan P, Das S, Salunke P. Occipital condyle syndrome due to tuberculosis: An uncommon cause unearthed by an unconventional approach. Neurol India 2018;66:551-3
Occipital condyle syndrome (OCS) manifests as neck pain with ipsilateral 12th nerve palsy. It is most commonly found consequent to skull base metastasis. Rarely, it may be encountered in tuberculous involvement of the occipital condyle., The paucity of cancellous element in the occipital bone along with its lack of lymphatic drainage has been advanced as reasons for the rarity of tuberculous involvement in this area. MRI may suggest the presence of OCS, but differentiating tuberculosis from metastasis using tissue/cytological diagnosis is important as these patients with tuberculous OCS respond well to antituberculous treatment (ATT) and rarely require surgery. An empirical ATT may not be a good idea even in endemic areas. However, at times, establishing a cytological diagnosis may not be easy due to the depth of the occipital condyle that makes these lesions inaccessible to a fine needle aspiration cytology (FNAC). Alternative routes must be sought to increase the yield from pathological tissues to establish the diagnosis. We report one such case of OCS where an inframastoid route was used to insert the needle and obtain tissue for diagnosis.
A 30-year old lady presented with progressive dysarthria and deviation of the tongue to the right side for a four-week duration [Figure 1]a along with history of neck pain radiating to the occipital region, restricted neck movements, and difficulty in lifting the head from the supine position. There was neither a history of trauma nor complaints of any other neurological deficits. Computed tomography (CT) and magnetic resonance imaging (MRI) [Figure 1]b,[Figure 1]c,[Figure 1]d,[Figure 1]e,[Figure 1]f,[Figure 1]g,[Figure 1]h scans of the craniovertebral junction (CVJ) showed irregular destruction of the right occipital condyle and the right C1 lateral mass with a paravertebral soft tissue collection. There was no obvious atlanto-axial dislocation. Her hematological investigations were normal. A CT-guided fine needle aspiration cytology (FNAC) revealed granulomatous inflammation suggestive of tuberculosis. She was started on antituberculous therapy (ATT) and was put on a sternal-occipital-mandibular-immobilizer (SOMI) brace. With time, her neck pain regressed and her tongue movement also improved.
|Figure 1: (a) Clinical photograph showing deviation of tongue to the right side on protrusion, suggestive of right hypoglossal nerve involvement. (b and c) Axial and coronal MRI showing involvement of right occipital condyle with minimal collection. (d) Coronal CT scan showing destruction of right occipital condyle. (e) 3D CT reconstruction showing needle in the right occipital condyle. (f–h) Axial 2D, posterolateral, and anterolateral view showing the trajectory of the needle through the infra-mastoid route|
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The establishment of the diagnosis is of paramount importance since empirical therapy based on the imaging alone may be inappropriate. Occipital condylar lesions may at times be inaccessible through a transoral FNAC. An alternative tract would be the posterolateral approach. The condyle lies medial to the mastoid and can be accessed below it. An anterolateral route (just behind the mandibular condyle) runs the risk of encountering the internal carotid artery, internal jugular vein, and the lower cranial nerves, whereas the presence of the facial nerve after it exits from the stylomastoid foramen precludes a pure lateral approach. In the posterolateral approach, injury to the vertebral artery is the only lurking danger. As the vertebral artery courses on the posterior arch of the atlas after exiting the transverse foramen of C1, flexing the neck and keeping the needle as close to the occipital squama as possible with its bevel directed upwards will ensure a safe trajectory. The course of the artery and the caliber of the vessel can be known using a computed tomographic angiogram or a Doppler ultrasound examination. An experienced radiologist with the help of a neurosurgeon can access this area through the route described.
The level of the angle of mandible corresponds to the C1 transverse process. Horizontal lines are drawn backwards, and vertical lines downwards from the tip of mastoid. The entry point is 1–1.5 cm posterior to the vertical line and above the horizontal line. The needle is angled up to avoid the horizontal part of the vertebral artery (traversing on the C1 posterior arch). The needle trajectory will hit the occiput above the OC1 joint. Fine adjustments with a CT scan can be made to biopsy the joint pathology. Moreover, any joint pathology will only displace the vertebral artery away from the joint and not bring it nearer.
To conclude, an awareness of the OCS, which is a rare presenting feature of CVJ tuberculosis, will enable an early diagnosis and initiate a treatment before dislocation or myelopathy sets in. Establishing the diagnosis is important in such cases. Alternative routes for performing the biopsy have to be considered if the standard one fails.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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