The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
mastication-induced clicking tinnitus, symptomatic patients may complain of recurrent infections of the EAC, otalgia, TMJ pain, conductive hearing loss, or salivary discharge into the EAC.2 – 4,6 During TMJ arthroscopy, inadvertent penetration through the bony defect may cause otologic complications such as perforation of the tympanic membrane, facial nerve damage, ossicular dislocation, and ear infection.5 Persistent foramen tympanicum may provide a route for spread of infection or tumorous conditions.10 Symptomatic persistent foramen tympanicum can be alleviated with surgical repair for closure of the bony defect using tragal cartilage, polypropylene implant, or titanium meshes.3,9,11 Though data on long-term postsurgical complications are insufficient, possible complications of this surgery can include mouth opening limitations, middle ear or TMJ damage, and movement of the inserted material.12 Thus, any treatment plan should carefully weigh the severity of symptoms, as well as the patient’s enthusiasm and suitability for surgical correction. In our cases, because the symptoms were not severe and the patients did not want surgery, conservative management was chosen. The patients were instructed not to chew foods on the affected side. After 2 months, masticationinduced clicking tinnitus disappeared and the size of the protruding mass was reduced in Case 2.
CONCLUSION Spontaneous herniation of TMJ tissue through a persistent foramen tympanicum is a rare condition, with mastication-induced tinnitus being one of the possible symptoms. Herniation into the EAC becomes more prominent when the mouth is closed. Surgical repair of the bony defect has been the treatment of choice. In cases when symptoms are trivial and patients do not want surgical treatment, however, conservative management such as avoidance of chewing foods on the affected side is a sound alternative.
REFERENCES 1. Heffez L, Anderson D, Mafee M. Developmental defects of the tympanic plate: case reports and review of the literature. J Oral Maxillofac Surg 1989;47:1336–1340 2. Moriyama M, Kodama S, Suzuki M. Spontaneous temporomandibular joint herniation into the external auditory canal: a case report and review of the literature. Laryngoscope 2005;115:2174–2177 3. Sharma PD, Dawkins RS. Patent foramen of Huschke and spontaneous salivary fistula. J Laryngol Otol 1984;98:83–85 4. Herzog S, Fiese R. Persistent foramen of Huschke: possible risk factor for otologic complications after arthroscopy of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1989;68:267–270 5. Applebaum EL, Berg LF, Kumar A, et al. Otologic complications following temporomandibular joint arthroscopy. Ann Otol Rhinol Laryngol 1988;97:675–679 6. Selesnick SH, Carew JF, DiBartolomeo JR. Herniation of the temporomandibular joint into the external auditory canal: a complication of otologic surgery. Am J Otol 1995;16:751–757 7. Mao JJ, Nah HD. Growth and development: hereditary and mechanical modulations. Am J Orthod Dentofacial Orthop 2004;125:676–689 8. Wang RG, Bingham B, Hawke M, et al. Persistence of the foramen of Huschke in the adult: an osteological study. J Otolaryngol 1991;20:251– 253 9. Park YH, Kim HJ, Park MH. Temporomandibular joint herniation into the external auditory canal. Laryngoscope 2010;120:2284–2288 10. Lacout A, Marsot-Dupuch K, Smoker WR, et al. Foramen tympanicum, or foramen of Huschke: pathologic cases and anatomic CT study. AJNR Am J Neuroradiol 2005;26:1317–1323 11. Saeed SR, Saeed NR, Brookes GB. Temporomandibular joint capsule prolapse: a technique of repair using autograft cartilage. J Laryngol Otol 1994;108:30–32 12. Anand VT, Latif MA, Smith WP. Defects of the external auditory canal: a new reconstruction technique. J Laryngol Otol 2000;114:279–282 #
2015 Mutaz B. Habal, MD
Brief Clinical Studies
A Middle Cranial Fossa Dermoid Cyst Treated by an Endonasal Endoscopic Approach Abdullah Durmaz, MD, U¨zeyir Yildizog˘lu, MD, Bahtiyar Polat, MD, and Murat Binar, MD Abstract: Dermoid cysts are rare, benign, congenital ectodermal inclusion cysts in the skull base, comprising skin supplements surrounded by squamous epithelium. In the period of embryological development, the cysts originate from ectodermal cells left behind in the cranial region by the closure of the neural tube and are primarily located at the midline, especially in the subarachnoid spaces. These lesions are usually asymptomatic and diagnosed incidentally. When the cysts reach large sizes, they can be symptomatic due to infection, rupture, or mass effect around neurovascular tissue. The cysts typically demonstrate accurate radiological diagnostic features. In this case report, we present a rare dermoid cyst in the middle cranial fossa, treated by an endonasal endoscopic approach. The endonasal endoscopic management of appropriate middle cranial fossa is discussed as a recent advance in the extended applications of endoscopic sinus surgery. Key Words: Dermoid cyst, endonasal endoscopic, middle cranial fossa
D
ermoid cysts are inclusion cysts with good prognosis. They are rarely seen in the central nervous system. The cysts are thought to originate from embryological rest structures remaining in the suture lines due to neural tube closure defect in weeks 3 to 5 of embryological development. The cysts are usually located in the midline and may be extradural and intradural.1 The structures may include skin supplements, such as hair follicles and sebaceous and sudoriferous glands, surrounded with squamous epithelium. The lesions are generally asymptomatic until reaching large sizes, at which time patients may present with stroke, cerebellar symptoms, and cranial nerve disorders, depending on the locations and sizes of the lesions. Acute manifestations, such as aseptic meningitis, ventriculitis, and hydrocephalus, may develop following cyst rupture.2,3 Computerized tomography (CT) and magnetic resonance imaging (MRI) features are sufficient for accurate diagnosis.4 The treatment is complete or partial surgical excision depending on location of the lesion.
CASE REPORT A 37-year-old male presented to our otolaryngology department with a complaint of vertigo. Benign paroxysmal positional vertigo was diagnosed after primary evaluation was done and Epley maneuver was performed. Although objective nystagmus was lost in follow-up, the complaint of persistent subjective dizziness remained. Further From the Department of Otolaryngology, Gulhane Military Medical Academy, Etlik, Ankara, Turkey. Received December 14, 2014. Accepted for publication January 13, 2015. Address correspondence and reprint requests to Abdullah Durmaz, MD, Department of Otolaryngology, Gulhane Military Medical Academy, Etlik, Ankara 06010, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001737
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 1. Magnetic resonance imaging of the dermoid cyst. A and D, Hyperintense extra-axial lesion in T1-weighted (T1w) images; B and E, hypointense in T2w images; C and F, lesion does not show contrast enhancement despite peripheral contrasting in T1w þ C images.
radiologic evaluation performed for persistent subjective vertigo revealed an incidental mass in the middle cranial fossa. MRI described a well-defined mass lesion in front of the cavernous sinus. The lesion was 11 12 mm with fat density consistent with lipoma. As it was hyperintense on T1 series, no statement is made about enhancement (Fig. 1). A CT angiogram was done to evaluate the relationship of the lesion with the vascular structures in close proximity, showing a mild, heterogeneous extraaxial lesion, 11 13 12 mm, localized in the anteroinferomedial part of the left temporal lobe. The posterior borders of the lesion comprised the anterior border of the cavernous sinus. Close proximity of the lesion to the cavernous segment of the left internal carotid artery (ICA) was demonstrated; however, there was no evidence of invasion of the vascular structures. Heterogenic fat density was described (Fig. 2). With these evidences, endonasal endoscopic excision was performed, and intraoperative findings revealed a dermoid cyst. The lesion was excised, except those parts of the cyst wall at close proximity to the cavernous sinus and cavernous ICA segment in posterior (Fig. 3). The histopathological investigation confirmed the diagnosis of dermoid cyst.
DISCUSSION Asymptomatic intracranial dermoid cysts are usually diagnosed incidentally. Due to slow growth, these cysts may reach very large sizes before showing any symptoms or signs. The growth rates of the cysts are associated with secretion of dermal elements and inflammatory attacks. Symptoms and signs depend on the locations of lesions and compression to adjacent structures. The cysts may rupture spontaneously, traumatically, or during surgery. When ruptured, contents of the cysts spread into the subarachnoid space and can manifest in a wide range of symptoms and signs, including headache, nausea, vomiting, visual disturbances, dizziness, epilepsy, aseptic chemical meningitis, hemiparesis, and mental changes.4,5 In our case, the dermoid cyst was about 1 cm in diameter at the base of the middle fossa and was detected incidentally on radiologic examination performed due to complaint of subjective dizziness. Radiological imaging methods provide valuable information in the diagnosis of dermoid cysts. Since supratentorial dermoid cysts mostly show close settlement to the midline, preoperative CT or MR angiography may be necessary to demonstrate relationship with major vascular structures. The dermoid cysts are low-density, highfat-content lesions and do not show contrast enhancement in CT.
FIGURE 2. Computed tomography imaging of dermoid cyst in (A) coronal, (B) axial, and (C) sagittal planes; close proximity of cyst to internal carotid artery is shown by white arrow.
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FIGURE 3. Endonasal endoscopic approach to middle cranial fossa. A, Maxillary antrostomy, posterior ethmoidectomy, and wide sphenoidotomy. B, Anterior wall of the cystic lesion has been reached by drill out and removal of pterygoid plates of sphenoid bone. C, Fatty cyst content drainage by opening of cyst wall. D, Epithelial debris and hair follicles in the cyst. E, Cavernous sinus at the posterior wall defined by angled endoscope as limit of excision. F, General picture of operation field after cyst is cleaned (aspirator points out infrasellar recess at midline). MS, maxillary sinus; PE, posterior ethmoid; PP, pterygoid plate; SS, sphenoid sinus. Dermoid cyst.
Heterogeneous images can be observed because of different components in the cyst. In the presence of a ruptured dermoid cyst, hypodense areas are visible due to fat particles in the subarachnoid space. If the cyst is ruptured through the ventricular system, hypodense fat particles and liquid–oil levels can be shown within the cerebrospinal fluid (CSF) and the ventricular system.5,6 In MRI, the appearance is hyperintense in T1-weighted images depending on the fat content, and predominantly hypointense or with variable signal intensity in T2-weighted images (Fig. 1). Heterogeneity can be observed due to different cyst components. When ruptured, hyperintense fat particles are observed in the subarachnoid space and ventricular system in T1-weighted images. Furthermore, liquid–oil levels may be observed in the ventricular system.4,5 The cyst itself does not show contrast enhancement, but peripheral contrasting can be seen due to inflammation around the lesion. Dermoid cysts have high valuable diagnostic radiological features; however, lipoma, epidermoid cyst, arachnoid cyst, craniopharyngioma, and teratoma should also be considered in differential diagnosis. In our case, lipoma was considered as a first diagnosis inadvertently because of its similar radiological features and lack of fat suppression images. Lipomas are often observed in the midline and supratentorial area. In MRI, they are shown as hyperintense on T1-weighted images and hypointense on T2-weighted images with well-defined borders and without contrast enhancement. Similar to dermoid cyst with these features, lipomas are suppressed in fat-suppressed images and appear hypointense. They also do not have cystic components.7 As fat-suppressed imaging had not been performed, the diagnosis of lipoma could not be excluded in our case. Epidermoid cysts are often observed in the cistern of the cerebellopontine angle and parasellar regions. In MRI, they appear hypointense on T1weighted images and hyperintense on T2-weighted images and do not show contrast enhancement. Epidermoid cysts rarely may appear hyperintense on T1-weighted sequences, hypointense on T2weighted sequences and may interfere with dermoid cyst.8,9 Solid components of teratomas may show contrast enhancement despite their fat content, calcifications, and cystic components.10 Dermoid cysts also may not be differentiated from epidermoid cysts if their rates of fat content are low.11 Hyperintense dermoid cysts can be differentiated from arachnoid cysts that include CSF by comparison with CSF in FLAIR sequences.12 The treatment of dermoid cysts is surgical excision with complete resection of the cyst wall. However, dermoid cysts located in the subarachnoid space tend to adhere tightly to adjacent structures.1 Partial resection can be done when the cyst is in close proximity to vital neurovascular structures.11,13,14 Excision of the dermoid cyst by endonasal endoscopy is gaining preference for dermoid cysts in the anterior skull base.15,16 In certain cases located in the middle cranial fossa, dermoid cysts can be removed by the #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
endonasal endoscopic approach. In our case, the lesion was in the middle cranial fossa, relatively small, anterior to the cavernous sinus, and in close proximity to a cavernous segment of ICA (Fig. 2). Due to a high-volume blood leak during excision of the posterior wall, the wall of the cyst was left behind to avoid complications. The endonasal endoscopic approach allowed reliable access to the cyst and provided a large drainage window for endoscopic follow-up. At 1-year follow-up, no recurrence occurred. Although vertigo was reported due to rupture of the dermoid cyst in parasellar region,17 there was no relationship between vertigo and the dermoid cyst in our case. Nevertheless, the complaint of subjective vertigo resolved after surgical treatment. In conclusion, although dermoid cysts can be asymptomatic until reaching large sizes, they can cause severe symptoms when ruptured through the subarachnoid space and ventricular system. CT and MRI have high accuracy for diagnosis. Lipoma, epidermoid cyst, arachnoid cyst, craniopharyngioma, and teratoma should be considered in the differential diagnosis. Suppression of lipoma in fat-suppressed sequences and uniform visualization are important features for differentiating these lesions from dermoid cysts. The treatment of dermoid cysts is surgical excision; however, complete excision may not be possible due to adhesion to surrounding structures. Endonasal endoscopic removal of appropriate middle cranial fossa lesions is a recent advance in the extended applications of sinus surgery, allowing for less-invasive procedures with lower morbidity.
REFERENCES 1. Lunardi P, Missori P. Supratentorial dermoid cysts. J Neurosurg 1991;75:262–266 2. Smith AS, Benson JE, Blaser SI, et al. Diagnosis of ruptured intracranial dermoid cyst: value of MR over CT. AJNR Am J Neuroradiol 1991;12:175–180 3. Karabulut N, Oguzkurt L. Tetraventricular hydrocephalus due to ruptured intracranial dermoid cyst. Eur Radiol 2000;10:1810–1811 4. Liu JK, Gottfried ON, Salzman KL, et al. Ruptured intracranial dermoid cysts: clinical, radiographic, and surgical features. Neurosurgery 2008;62:377–384 5. Altay H, Kitis¸ O, Calli C, et al. A spinal dermoid tumor that ruptured into the subarachnoidal space and syrinx cavity. Diagn Interv Radiol 2006;12:171–173 6. Wilms G, Casselman J, Demaerel P, et al. CT and MRI of ruptured intracranial dermoids. Neurolradiology 1991;33:149–151 7. Osborn AG, Blaser SI, Salzman KL, et al. Diagnostic Imaging: Brain. 2nd ed. Canada: Friesens; 2004:1-22-25 8. Gualdi GF, Di Biasi C, Trasimeni G, et al. Unusual MR and CT appearance of an epidermoid tumor. AJNR Am J Neuroradiol 1991;12:771–772 9. Kallmes DF, Provenzale JM, Cloft HJ, et al. Typical and atypical MR imaging features of intracranial epidermoid tumours. AJR Am J Roentgenol 1997;169:883–887 10. Fujimaki T, Matsutani T, Funada N, et al. CT and MRI features of intracranial germ cell tumors. J Neurooncol 1994;19:217–226 11. Ageshio N, Shimono T, Goto T, et al. Imaging appearance of petrous apex dermoid cysts containing little or no fat. Jpn J Radiol 2013;31:133–137 12. Tsuchiya K, Mizertani Y, Hachiya J. Preliminary evaluation of fluid attentuated inversion recovery MR in the diagnosis of intracranial tumors. AJNR 1996;17:1081–1086 13. Akdemir G, Dag˘liog˘lu E, Ergu¨ngo¨r MF. Dermoid lesion of the cavernous sinus: case report and review of the literature. Neurosurg Rev 2004;27:294–298 14. Tun K, Celikmez RC, Okutan O, et al. Dermoid tumour of the lateral wall of the cavernous sinus. J Clin Neurosci 2008;15:820–823 15. Schuster D, Riley KO, Cure JK, et al. Endoscopic resection of intracranial dermoid cysts. J Laryngol Otol 2011;125:423–427 16. Du¨z B, Secer HI, Tosun F, et al. Endoscopic endonasal resection of a midline intradural frontobasal dermoid tumour. Minim Invasive Neurosurg 2007;50:363–366 #
2015 Mutaz B. Habal, MD
Brief Clinical Studies
17. Asil K, Gunduz Y, Ayhan LT, et al. Spontaneous rupture of intracranial dermoid tumor in a patient with vertigo. Computed tomography and magnetic resonance imaging findings. Pol J Radiol 2013;78:79–82
Secondary Improvement in Static Facial Reanimation Surgeries: Increase of Nasal Function Gurkan Kayabasoglu, MD and Alpen Nacar Objective: The aim of this study was to measure the effect of the static reanimation operation administered to patients with facial paralysis on nasal function area by comparing patients’ preoperative and postoperative subjective perception of the nasal airflow. Materials and Method: We applied the Nasal Obstruction Symptom Evaluation (NOSE) scale to 13 patients who underwent static reanimation because of facial palsies, both preoperatively and postoperatively, and results were compared statistically. The changes in nasal base angulation were recorded and compared based on the photographs of patients taken before and after the surgery. Results: Following the static reanimation operation, 76% (10/13) of the patients reported a subjective improvement in the nasal airflow, whereas 24% (3/13) did not report any change. Mean preoperative and postoperative NOSE scale scores were 66.92 9.90 and 36.15 9.61, respectively. The change in mean NOSE scale score was statistically significant (P < 0.001). In the preoperative and postoperative comparison of the photographs taken from the front view of the patients, a decreased nasal base angulation compared with preoperative period was detected in 8 (61.6%) patients. Conclusions: A statistically significant increase in subjective perception about nasal function was observed after the static facial reanimation; however, it is not certain whether this effect can be considered persistent. Long-term studies conducted on a larger patient population will provide beneficial results. Key Words: Facelift, facial paralysis, nasal obstruction, nose, rehabilitation
T
he anatomy of the nasal valve was first described by Mink in 1903, and Kasperbauer and Kern made a further distinction
From the Sakarya University, Faculty of Medicine, Department of Otorhinolaryngology, Sakarya, Turkey. Received July 24, 2014. Accepted for publication February 3, 2015. Address correspondence and reprint requests to Gurkan Kayabasoglu, MD, Assistant Professor, Adnan Menderes Cad. No 145 Adapazari, Sakarya 54100, Turkey; E-mail: [email protected] This study was presented at 11th International Otolaryngology, Head and Neck Surgery Congress, April 2014, Ankara, Turkey. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001769
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Volume 26, Number 4, June 2015
mastication-induced clicking tinnitus, symptomatic patients may complain of recurrent infections of the EAC, otalgia, TMJ pain, conductive hearing loss, or salivary discharge into the EAC.2 – 4,6 During TMJ arthroscopy, inadvertent penetration through the bony defect may cause otologic complications such as perforation of the tympanic membrane, facial nerve damage, ossicular dislocation, and ear infection.5 Persistent foramen tympanicum may provide a route for spread of infection or tumorous conditions.10 Symptomatic persistent foramen tympanicum can be alleviated with surgical repair for closure of the bony defect using tragal cartilage, polypropylene implant, or titanium meshes.3,9,11 Though data on long-term postsurgical complications are insufficient, possible complications of this surgery can include mouth opening limitations, middle ear or TMJ damage, and movement of the inserted material.12 Thus, any treatment plan should carefully weigh the severity of symptoms, as well as the patient’s enthusiasm and suitability for surgical correction. In our cases, because the symptoms were not severe and the patients did not want surgery, conservative management was chosen. The patients were instructed not to chew foods on the affected side. After 2 months, masticationinduced clicking tinnitus disappeared and the size of the protruding mass was reduced in Case 2.
CONCLUSION Spontaneous herniation of TMJ tissue through a persistent foramen tympanicum is a rare condition, with mastication-induced tinnitus being one of the possible symptoms. Herniation into the EAC becomes more prominent when the mouth is closed. Surgical repair of the bony defect has been the treatment of choice. In cases when symptoms are trivial and patients do not want surgical treatment, however, conservative management such as avoidance of chewing foods on the affected side is a sound alternative.
REFERENCES 1. Heffez L, Anderson D, Mafee M. Developmental defects of the tympanic plate: case reports and review of the literature. J Oral Maxillofac Surg 1989;47:1336–1340 2. Moriyama M, Kodama S, Suzuki M. Spontaneous temporomandibular joint herniation into the external auditory canal: a case report and review of the literature. Laryngoscope 2005;115:2174–2177 3. Sharma PD, Dawkins RS. Patent foramen of Huschke and spontaneous salivary fistula. J Laryngol Otol 1984;98:83–85 4. Herzog S, Fiese R. Persistent foramen of Huschke: possible risk factor for otologic complications after arthroscopy of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1989;68:267–270 5. Applebaum EL, Berg LF, Kumar A, et al. Otologic complications following temporomandibular joint arthroscopy. Ann Otol Rhinol Laryngol 1988;97:675–679 6. Selesnick SH, Carew JF, DiBartolomeo JR. Herniation of the temporomandibular joint into the external auditory canal: a complication of otologic surgery. Am J Otol 1995;16:751–757 7. Mao JJ, Nah HD. Growth and development: hereditary and mechanical modulations. Am J Orthod Dentofacial Orthop 2004;125:676–689 8. Wang RG, Bingham B, Hawke M, et al. Persistence of the foramen of Huschke in the adult: an osteological study. J Otolaryngol 1991;20:251– 253 9. Park YH, Kim HJ, Park MH. Temporomandibular joint herniation into the external auditory canal. Laryngoscope 2010;120:2284–2288 10. Lacout A, Marsot-Dupuch K, Smoker WR, et al. Foramen tympanicum, or foramen of Huschke: pathologic cases and anatomic CT study. AJNR Am J Neuroradiol 2005;26:1317–1323 11. Saeed SR, Saeed NR, Brookes GB. Temporomandibular joint capsule prolapse: a technique of repair using autograft cartilage. J Laryngol Otol 1994;108:30–32 12. Anand VT, Latif MA, Smith WP. Defects of the external auditory canal: a new reconstruction technique. J Laryngol Otol 2000;114:279–282 #
2015 Mutaz B. Habal, MD
Brief Clinical Studies
A Middle Cranial Fossa Dermoid Cyst Treated by an Endonasal Endoscopic Approach Abdullah Durmaz, MD, U¨zeyir Yildizog˘lu, MD, Bahtiyar Polat, MD, and Murat Binar, MD Abstract: Dermoid cysts are rare, benign, congenital ectodermal inclusion cysts in the skull base, comprising skin supplements surrounded by squamous epithelium. In the period of embryological development, the cysts originate from ectodermal cells left behind in the cranial region by the closure of the neural tube and are primarily located at the midline, especially in the subarachnoid spaces. These lesions are usually asymptomatic and diagnosed incidentally. When the cysts reach large sizes, they can be symptomatic due to infection, rupture, or mass effect around neurovascular tissue. The cysts typically demonstrate accurate radiological diagnostic features. In this case report, we present a rare dermoid cyst in the middle cranial fossa, treated by an endonasal endoscopic approach. The endonasal endoscopic management of appropriate middle cranial fossa is discussed as a recent advance in the extended applications of endoscopic sinus surgery. Key Words: Dermoid cyst, endonasal endoscopic, middle cranial fossa
D
ermoid cysts are inclusion cysts with good prognosis. They are rarely seen in the central nervous system. The cysts are thought to originate from embryological rest structures remaining in the suture lines due to neural tube closure defect in weeks 3 to 5 of embryological development. The cysts are usually located in the midline and may be extradural and intradural.1 The structures may include skin supplements, such as hair follicles and sebaceous and sudoriferous glands, surrounded with squamous epithelium. The lesions are generally asymptomatic until reaching large sizes, at which time patients may present with stroke, cerebellar symptoms, and cranial nerve disorders, depending on the locations and sizes of the lesions. Acute manifestations, such as aseptic meningitis, ventriculitis, and hydrocephalus, may develop following cyst rupture.2,3 Computerized tomography (CT) and magnetic resonance imaging (MRI) features are sufficient for accurate diagnosis.4 The treatment is complete or partial surgical excision depending on location of the lesion.
CASE REPORT A 37-year-old male presented to our otolaryngology department with a complaint of vertigo. Benign paroxysmal positional vertigo was diagnosed after primary evaluation was done and Epley maneuver was performed. Although objective nystagmus was lost in follow-up, the complaint of persistent subjective dizziness remained. Further From the Department of Otolaryngology, Gulhane Military Medical Academy, Etlik, Ankara, Turkey. Received December 14, 2014. Accepted for publication January 13, 2015. Address correspondence and reprint requests to Abdullah Durmaz, MD, Department of Otolaryngology, Gulhane Military Medical Academy, Etlik, Ankara 06010, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001737
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 1. Magnetic resonance imaging of the dermoid cyst. A and D, Hyperintense extra-axial lesion in T1-weighted (T1w) images; B and E, hypointense in T2w images; C and F, lesion does not show contrast enhancement despite peripheral contrasting in T1w þ C images.
radiologic evaluation performed for persistent subjective vertigo revealed an incidental mass in the middle cranial fossa. MRI described a well-defined mass lesion in front of the cavernous sinus. The lesion was 11 12 mm with fat density consistent with lipoma. As it was hyperintense on T1 series, no statement is made about enhancement (Fig. 1). A CT angiogram was done to evaluate the relationship of the lesion with the vascular structures in close proximity, showing a mild, heterogeneous extraaxial lesion, 11 13 12 mm, localized in the anteroinferomedial part of the left temporal lobe. The posterior borders of the lesion comprised the anterior border of the cavernous sinus. Close proximity of the lesion to the cavernous segment of the left internal carotid artery (ICA) was demonstrated; however, there was no evidence of invasion of the vascular structures. Heterogenic fat density was described (Fig. 2). With these evidences, endonasal endoscopic excision was performed, and intraoperative findings revealed a dermoid cyst. The lesion was excised, except those parts of the cyst wall at close proximity to the cavernous sinus and cavernous ICA segment in posterior (Fig. 3). The histopathological investigation confirmed the diagnosis of dermoid cyst.
DISCUSSION Asymptomatic intracranial dermoid cysts are usually diagnosed incidentally. Due to slow growth, these cysts may reach very large sizes before showing any symptoms or signs. The growth rates of the cysts are associated with secretion of dermal elements and inflammatory attacks. Symptoms and signs depend on the locations of lesions and compression to adjacent structures. The cysts may rupture spontaneously, traumatically, or during surgery. When ruptured, contents of the cysts spread into the subarachnoid space and can manifest in a wide range of symptoms and signs, including headache, nausea, vomiting, visual disturbances, dizziness, epilepsy, aseptic chemical meningitis, hemiparesis, and mental changes.4,5 In our case, the dermoid cyst was about 1 cm in diameter at the base of the middle fossa and was detected incidentally on radiologic examination performed due to complaint of subjective dizziness. Radiological imaging methods provide valuable information in the diagnosis of dermoid cysts. Since supratentorial dermoid cysts mostly show close settlement to the midline, preoperative CT or MR angiography may be necessary to demonstrate relationship with major vascular structures. The dermoid cysts are low-density, highfat-content lesions and do not show contrast enhancement in CT.
FIGURE 2. Computed tomography imaging of dermoid cyst in (A) coronal, (B) axial, and (C) sagittal planes; close proximity of cyst to internal carotid artery is shown by white arrow.
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Volume 26, Number 4, June 2015
FIGURE 3. Endonasal endoscopic approach to middle cranial fossa. A, Maxillary antrostomy, posterior ethmoidectomy, and wide sphenoidotomy. B, Anterior wall of the cystic lesion has been reached by drill out and removal of pterygoid plates of sphenoid bone. C, Fatty cyst content drainage by opening of cyst wall. D, Epithelial debris and hair follicles in the cyst. E, Cavernous sinus at the posterior wall defined by angled endoscope as limit of excision. F, General picture of operation field after cyst is cleaned (aspirator points out infrasellar recess at midline). MS, maxillary sinus; PE, posterior ethmoid; PP, pterygoid plate; SS, sphenoid sinus. Dermoid cyst.
Heterogeneous images can be observed because of different components in the cyst. In the presence of a ruptured dermoid cyst, hypodense areas are visible due to fat particles in the subarachnoid space. If the cyst is ruptured through the ventricular system, hypodense fat particles and liquid–oil levels can be shown within the cerebrospinal fluid (CSF) and the ventricular system.5,6 In MRI, the appearance is hyperintense in T1-weighted images depending on the fat content, and predominantly hypointense or with variable signal intensity in T2-weighted images (Fig. 1). Heterogeneity can be observed due to different cyst components. When ruptured, hyperintense fat particles are observed in the subarachnoid space and ventricular system in T1-weighted images. Furthermore, liquid–oil levels may be observed in the ventricular system.4,5 The cyst itself does not show contrast enhancement, but peripheral contrasting can be seen due to inflammation around the lesion. Dermoid cysts have high valuable diagnostic radiological features; however, lipoma, epidermoid cyst, arachnoid cyst, craniopharyngioma, and teratoma should also be considered in differential diagnosis. In our case, lipoma was considered as a first diagnosis inadvertently because of its similar radiological features and lack of fat suppression images. Lipomas are often observed in the midline and supratentorial area. In MRI, they are shown as hyperintense on T1-weighted images and hypointense on T2-weighted images with well-defined borders and without contrast enhancement. Similar to dermoid cyst with these features, lipomas are suppressed in fat-suppressed images and appear hypointense. They also do not have cystic components.7 As fat-suppressed imaging had not been performed, the diagnosis of lipoma could not be excluded in our case. Epidermoid cysts are often observed in the cistern of the cerebellopontine angle and parasellar regions. In MRI, they appear hypointense on T1weighted images and hyperintense on T2-weighted images and do not show contrast enhancement. Epidermoid cysts rarely may appear hyperintense on T1-weighted sequences, hypointense on T2weighted sequences and may interfere with dermoid cyst.8,9 Solid components of teratomas may show contrast enhancement despite their fat content, calcifications, and cystic components.10 Dermoid cysts also may not be differentiated from epidermoid cysts if their rates of fat content are low.11 Hyperintense dermoid cysts can be differentiated from arachnoid cysts that include CSF by comparison with CSF in FLAIR sequences.12 The treatment of dermoid cysts is surgical excision with complete resection of the cyst wall. However, dermoid cysts located in the subarachnoid space tend to adhere tightly to adjacent structures.1 Partial resection can be done when the cyst is in close proximity to vital neurovascular structures.11,13,14 Excision of the dermoid cyst by endonasal endoscopy is gaining preference for dermoid cysts in the anterior skull base.15,16 In certain cases located in the middle cranial fossa, dermoid cysts can be removed by the #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
endonasal endoscopic approach. In our case, the lesion was in the middle cranial fossa, relatively small, anterior to the cavernous sinus, and in close proximity to a cavernous segment of ICA (Fig. 2). Due to a high-volume blood leak during excision of the posterior wall, the wall of the cyst was left behind to avoid complications. The endonasal endoscopic approach allowed reliable access to the cyst and provided a large drainage window for endoscopic follow-up. At 1-year follow-up, no recurrence occurred. Although vertigo was reported due to rupture of the dermoid cyst in parasellar region,17 there was no relationship between vertigo and the dermoid cyst in our case. Nevertheless, the complaint of subjective vertigo resolved after surgical treatment. In conclusion, although dermoid cysts can be asymptomatic until reaching large sizes, they can cause severe symptoms when ruptured through the subarachnoid space and ventricular system. CT and MRI have high accuracy for diagnosis. Lipoma, epidermoid cyst, arachnoid cyst, craniopharyngioma, and teratoma should be considered in the differential diagnosis. Suppression of lipoma in fat-suppressed sequences and uniform visualization are important features for differentiating these lesions from dermoid cysts. The treatment of dermoid cysts is surgical excision; however, complete excision may not be possible due to adhesion to surrounding structures. Endonasal endoscopic removal of appropriate middle cranial fossa lesions is a recent advance in the extended applications of sinus surgery, allowing for less-invasive procedures with lower morbidity.
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2015 Mutaz B. Habal, MD
Brief Clinical Studies
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Secondary Improvement in Static Facial Reanimation Surgeries: Increase of Nasal Function Gurkan Kayabasoglu, MD and Alpen Nacar Objective: The aim of this study was to measure the effect of the static reanimation operation administered to patients with facial paralysis on nasal function area by comparing patients’ preoperative and postoperative subjective perception of the nasal airflow. Materials and Method: We applied the Nasal Obstruction Symptom Evaluation (NOSE) scale to 13 patients who underwent static reanimation because of facial palsies, both preoperatively and postoperatively, and results were compared statistically. The changes in nasal base angulation were recorded and compared based on the photographs of patients taken before and after the surgery. Results: Following the static reanimation operation, 76% (10/13) of the patients reported a subjective improvement in the nasal airflow, whereas 24% (3/13) did not report any change. Mean preoperative and postoperative NOSE scale scores were 66.92 9.90 and 36.15 9.61, respectively. The change in mean NOSE scale score was statistically significant (P < 0.001). In the preoperative and postoperative comparison of the photographs taken from the front view of the patients, a decreased nasal base angulation compared with preoperative period was detected in 8 (61.6%) patients. Conclusions: A statistically significant increase in subjective perception about nasal function was observed after the static facial reanimation; however, it is not certain whether this effect can be considered persistent. Long-term studies conducted on a larger patient population will provide beneficial results. Key Words: Facelift, facial paralysis, nasal obstruction, nose, rehabilitation
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he anatomy of the nasal valve was first described by Mink in 1903, and Kasperbauer and Kern made a further distinction
From the Sakarya University, Faculty of Medicine, Department of Otorhinolaryngology, Sakarya, Turkey. Received July 24, 2014. Accepted for publication February 3, 2015. Address correspondence and reprint requests to Gurkan Kayabasoglu, MD, Assistant Professor, Adnan Menderes Cad. No 145 Adapazari, Sakarya 54100, Turkey; E-mail: [email protected] This study was presented at 11th International Otolaryngology, Head and Neck Surgery Congress, April 2014, Ankara, Turkey. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001769
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
