Trigeminal Neuralgia Due to Petrosal Bone Deformity.

BACKGROUND: There have been a few previous reports of trigeminal neuralgia caused by bony structures. We report a rare case of trigeminal neuralgia caused by petrous bone deformity. CASE DESCRIPTION: A-43-year-old man with facial pain in the left maxillary and mandibular divisions of the trigeminal nerve was referred to our hospital. Computed tomography showed bone hyperplasia protruding into the left cerebellopontine cistern, compressing the left trigeminal nerve. Administration of carbamazepine ameliorated facial pain, but the effect was unsatisfactory, and microvascular decompression was performed through the anterior transpetrosal approach. The protruding petrous bone was drilled out to release compression of the trigeminal nerve, thus straightening the deviated trajectory of the nerve. The superior cerebellar artery adjacent to the thickened petrosal bone seemed to have compressed the trigeminal nerve and was also transposed. The facial pain disappeared completely after microvascular decompression surgery. CONCLUSIONS: The anterior transpetrosal approach is an appropriate and essential strategy for trigeminal neuralgia caused by petrous bone deformity of the petrous apex.

Bilateral duplication of the abducens nerve - case study.

The abducens nerve is characterized by a long intracranial course and complex topographical relationships. Anatomical knowledge may help to understand both the etiology and clinical symptoms of abducens nerve palsy. Typically, the single trunk of the abducens nerve travels on both sides. However, occasionally different variants of unilateral or bilateral duplications of the abducens nerve may be observed. The presented paper is a detailed anatomical description of bilateral duplication of the abducens nerve, with atypical appearance of the nerve in the cavernous sinus and normal distribution within the lateral rectus muscle on both sides of one cadaver. On the right side both trunks of the abducens nerve fused within the subarachnoid space and pierced the dura mater together. On the left side both trunks of the duplicated abducens nerve pierced the dura mater separately, entered the petrous apex separately and fused just below the petrosphenoidal ligament. Within the cavernous sinus the nerve divided once again into two filaments, which reunited into one trunk a er crossing the horizontal segment of the intracavernous part of internal carotid artery. The orbital segments of the abducens nerve showed a typical course on both sides. Duplication of the abducens nerve is anatomical variation which should be taken into account during diagnostic and surgical procedures performed within the petroclival region and cavernous sinus.

Mandibular Myalgia and Miniscule Meckel's Caves.

Trigeminal neuropathy manifests as episodic sharp, shooting pain in the maxillofacial region. Contributory etiologies are myriad, ranging from central pathology affecting its origin in the brainstem to peripheral processes affecting their distal-most insertion sites. We present a case of bilateral hypoplastic Meckel's caves in an adult patient leading to the clinical symptomology of trigeminal neuralgia. To the best of our knowledge, this is the only report of its kind highlighting this anatomic variant.

Incidence and morphometry of sellar bridges and related foramina in dry skulls: Their significance in middle cranial fossa surgery.

PURPOSE: The current study investigated the incidence, morphology and morphometry of the ossified ligaments expanding between petrous bone and posterior clinoid processes and in between the anterior, middle and posterior clinoid processes. Side symmetry, gender dimorphism and age influence were also studied. MATERIALS AND METHODS: A total of 123 adult Greek dry skulls were observed. RESULTS: A caroticoclinoid bar (CCB) was found in 60.2%. Partial CCBs appeared more commonly (36.6%) than complete (23.6%). The caroticoclinoid foramen (CCF) was symmetrical on both sides and genders. An anterior interclinoid, a posterior petroclinoid and a partial posterior interclinoid bar appeared in 19.5%, 6.5% and 2.4%, respectively. Osseous spurs posterolateral to the posterior clinoid process were present in 5.7%. CONCLUSION: The study highlights important morphometric details about osseous bars of the sella region and the related CCF in Greek skulls. Notable differences in the incidence of these bars in Greek individuals compared with findings from other populations highlight the growing awareness of ethnic differences in skull base landmarks. Variations and surgically oriented measurements provided by this study may benefit clinicians involved in the treatment of the middle cranial fossa pathology, enriching understanding of the complicated regional anatomy. Preoperative sellar area mapping is essential, by using computed tomography images, since modification of the surgical approach may be required in cases of severe ossification.

Surgically Cured, Relapsed Pneumococcal Meningitis Due to Bone Defects, Non-invasively Identified by Three-dimensional Multi-detector Computed Tomography.

A 43-year-old Japanese man presented with a history of bacterial meningitis (BM). He was admitted to our department with a one-day history of headache and was diagnosed with relapse of BM based on the cerebrospinal fluid findings. The conventional imaging studies showed serial findings suggesting left otitis media, a temporal cephalocele, and meningitis. Three-dimensional multi-detector computed tomography (3D-MDCT) showed left petrous bone defects caused by the otitis media, and curative surgical treatment was performed. Skull bone structural abnormalities should be considered a cause of relapsed BM. 3D-MDCT was useful for revealing the causal minimal bone abnormality and performing pre-surgical mapping.

[Influence of trigeminal nerve lesion on facial growth: study of two cases of Goldenhar syndrome]. / Influence de l'atteinte trigéminale sur la croissance faciale : étude de deux cas de syndrome de Goldenhar.

INTRODUCTION: This cases report confirms the hypothesis that embryonic and maxillofacial growth are influenced by the peripheral nervous system, including the trigeminal nerve (V). So, it's interesting to use the stigma of the trigeminal nerve as landmarks to analyze the maxillofacial volume and understand its growth. The aim of this study is to evaluate the validity of the three-dimensional cephalometric analysis of Treil based on trigeminal landmarks. CASE PRESENTATION: The first case is a caucasian female child with Goldenhar syndrome. The second case is a caucasian male adult affected by the same syndrome. In both cases, brain MRI showed an unilateral trigeminal nerve lesion, ipsilateral to the facial dysmorphia. CONCLUSION: The results of this radiological study tend to prove the primary role of the trigeminal nerve in craniofacial growth. These cases demonstrate the validity of the theory of Moss. They are one of anatomo-functional justifications of the three-dimensional cephalometric biometry of Treil based on trigeminal nerve landmarks.

Bilateral aberrant infratentorial vasculature: a rare cadaveric encounter

During a cadaveric dissection course, abnormalities of the infratentorial vasculature were noted. Following removal of the brain, the posterior cranial fossa showed the left labyrinthine artery splitting into two branches: one entered the internal auditory meatus (IAM) with the eighth cranial nerve, and the other pierced the petrous temporal bone just posterior to the IAM in the region of the subarcuate fossa. On the right side, the anterior inferior cerebellar artery formed a loop that was embedded in the dura just posterior to the IAM, but no vessels were seen entering the IAM. Further dissection into the petrous temporal bone showed the loop directed towards the region of the subarcuate fossa, and the injection of coloured latex confirmed fine arterial distribution of the latex on the surface of the deep part of the eighth cranial nerve. Eight other cadavers dissected in the same course did not show any such anomalies. Knowledge of these vascular variations is important for surgical exposure of the posterior cranial fossa

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Fortificación del arroz para corregir la deficiencia de micronutrientes en niños de 6 a 59 meses de edad / Rice fortification to correct micronutrient deficiency in children 6-59 months old

Objetivo. Realizar una revisión sistemática de la literatura sobre la eficacia del consumo de arroz fortificado en el incremento de los niveles de hierro y otros micronutrientes en niños de 6 a 59 meses de edad, con la finalidad de evaluar su utilidad como intervención de salud pública. Métodos. La búsqueda se realizó en las bases de datos Medline, Embase, The Cochrane Library y LILACS. Se incluyeron ensayos clínicos aleatorizados (ECA) que evaluaron el consumo de arroz fortificado comparado con placebo u otras formas de intervención sobre la mejora de los niveles de hierro y otros micronutrientes. Para evaluar la calidad metodológica, se utilizó la lista de verificación CONSORT®. El riesgo de sesgo de los estudios se evaluó según la metodología de la Colaboración Cochrane®. Resultados. Se incluyeron siete ECA en la revisión. Todos los estudios mostraron mejoras significativas en indicadores del estado nutricional de hierro en los grupos intervenidos, sin reportar efectos adversos. No se evidenció mejoría en los niveles de vitamina A, ni en los indicadores antropométricos de peso y talla como resultado secundario de la intervención. Los estudios incluidos mostraron calidad metodológica moderada. Conclusiones. La fortificación del arroz representó una estrategia de intervención eficaz para corregir la deficiencia de hierro en la población infantil menor de cinco años. Su implementación como medida de salud pública requiere estudios locales que evalúen su efectividad en intervenciones a largo plazo y en mayor escala.

Objective. To carry out a systematic review of the literature on the effectiveness of fortified rice consumption in terms of increasing levels of iron and other micro­nutrients in children aged 6-59 months, with a view to evaluating its usefulness as a public health intervention. Methods. A search was conducted in MEDLINE, Embase, Cochrane Library, and LILACS databases. The review included randomized clinical trials (RCTs) that assessed the consumption of fortified rice, compared with a placebo or other forms of intervention, in terms of enhanced levels of iron and other micronutrients. The CONSORT® checklist was used to assess methodological quality. The risk of bias in the studies was assessed using the Cochrane® Collaboration methodology. Results. Seven RCTs were included in the review. All the studies showed significant improvements in indicators of nutritional iron status in the intervention groups, without reporting adverse effects. There was no evidence of improvement in vitamin A levels or in anthropometric indicators of weight and height as a secondary result of the intervention. The included studies showed moderate methodological quality. Conclusions. Rice fortification was an effective intervention strategy to correct iron deficiency in children under age 5. For implementation as a public health measure, local studies are needed to assess its effectiveness in long-term and large-scale interventions.

Petrosquamosal sinus discovered during mastoidectomy, and its radiologic appearance on temporal bone CT: case report and brief review.

We report the case of a 47-year-old woman who underwent a mastoidectomy. Preoperative computed tomography demonstrated an unusually distended bony canal that passed through the superolateral portion of the right petrous bone. Intraoperatively, we identified the anomaly as a petrosquamosal sinus (PSS). This unusually dilated venous channel had arisen from the adjacent sigmoid sinus. A PSS is an emissary vein of the posterior fossa that courses along the petrosquamosal junction, connecting the sigmoid or transverse sinus with the extracranial venous system. While it usually regresses during fetal life, a dilated PSS occasionally persists into adulthood. Its anatomic course may lead to problematic bleeding during mastoidectomy.

[Malformations and abnormalities of the petrous portion of the temporal bone]. / Fehlbildungen und Missbildungen des Felsenbeins.

High-resolution computed tomography (HRCT) is the procedure of choice in the diagnostics of abnormalities of the middle and inner ear. It allows a detailed presentation of anatomical features and achieves the prerequisites for selection of the various therapeutic options. The highly diverse abnormalities can be described using detailed imaging analyses. Malformations with an abnormally developed modiolus are assumed to be early embryological defects, such as the classical Mondini dysplasia. The essential therapeutic option for middle ear deformities is still a cochlear implant. The domain of magnetic resonance imaging (MRI) is not only in the analysis of the cochlear nerve and for exclusion of fibrosis or ossification of the labyrinth but is also able to visualize details of isolated malformations, such as an extended vestibular aqueduct or subtle alterations to the vestibule or can visualize them better in comparison to CT. Radiological diagnostics are used not only for classification but also to recognize typical clinical problem situations and play a key role in the diagnostics of hearing disorders and selection of the optimal therapeutic procedure.

Congenital aplasia of the external ear canal and total dehiscence of mastoid-tympanic segment of the facial nerve as a cause of recurrent facial paralysis.

Facial nerve (FN) macrodehiscence, in contrast to microdehiscence, generally occurs as a result of chronic otitis media and is rarely seen congenitally. A patient with normal hearing who had no history of ear disease or ear operation came to the clinic with recurrent facial paralysis (FP) and frequent blockage of the external ear canal with epithelial debris complaints. In the explorative ear surgery, we observed that the posterior wall of the external ear canal or tympanic ring was absent, a large external ear cavity was covered with a thin skin, the FN was under the skin, and the tympanic-mastoid segment of the FN and chorda tympani extending to the stylomastoid foramen was completely open. FP episodes were associated with the unprotected FN.To prevent an attack of FP, and to self-clean the external ears, mastoid obliteration surgery was performed, and the mastoid segment of the FN was covered with a conchal cartilage graft. This case was diagnosed as congenital aplasia of the external ear canal due to the tympanic bone aplasia-mastoid bone hypoplasia, and the dehiscence of the mastoid-tympanic segment of the FN, and as a cause of recurrent FP, has never to date been identified.

Meckel's cave anatomic variation.

We present a rare radiographic abnormality found in a patient who consulted us for progressive left hearing loss.

Coexistence of a pseudolesion and a true lesion in the same location: a rare misleading imaging finding.

Congenital cholesteatoma and asymmetric fatty marrow are both common masses that appear as imaging "lesions" in the petrous apex, but their treatment modalities are very different. Accurate preoperative recognition by computed tomography and magnetic resonance imaging is, therefore, important for planning appropriate management strategies. We report a case with coexisting congenital cholesteatoma and asymmetric fatty marrow in the same petrous bone. The 2 lesions were indistinguishable on high-resolution computed tomographic images and were only identified on fat-suppressed magnetic resonance imaging sequences. This is the first report of these 2 lesions coexisting, leading to a rare misleading imaging finding.

Temporal bone abnormalities in children with GJB2 mutations.

OBJECTIVES: To determine the incidence of temporal bone abnormalities in children with sensorineural hearing loss (SNHL) and pathogenic biallelic GJB2 mutations. STUDY DESIGN: Retrospective analysis of a large cohort of pediatric patients with biallelic GJB2 mutations and SNHL (observational case series). METHODS: Blinded review of all available temporal bone computed tomographic (CT) and magnetic resonance imaging (MRI) studies in this cohort. RESULTS: Out of 158 patients with biallelic GJB2 mutations, 113 had CT and/or MRI studies available for review. Definite, although generally subtle, inner ear abnormalities were present in 12/113. There were malformations of the semicircular canals (SCC) in 4/12, of the internal auditory canal in 2/12, of the cochlear nerve canal (CNC) in 6, and unilateral cochlear malformation in 1/12. MRI in 1/5 showed mildly hypoplastic cochlear nerve. There was no correlation between SNHL severity and presence/absence/type of malformations or genotype. CONCLUSIONS: Our study of 113 biallelic GJB2 patients with SNHL and temporal bone imaging is the largest study to date. We found only 10% had any abnormalities, most subtle, and none had EVA. Additionally, there was no correlation between SNHL severity and presence/absence/type of malformations or genotype. Disparities between our group and previous reports may be due to differences in degree of hearing loss, types of mutations, populations studied, and radiologic factors for both image acquisition and interpretation.

Petrous bone pneumatization is a risk factor for cerebrospinal fluid fistula following vestibular schwannoma surgery.

BACKGROUND: For the prevention of postoperative CSF fistula a better understanding of origins and risk factors is necessary. OBJECTIVE: To identify the petrous bone air cell volume as a risk factor for developing CSF fistula, we performed a retrospective analysis. METHODS: From 2000 to 2007 519 patients had a retrosigmoidal surgical removal of a vestibular schwannoma. The 22 who had a postoperative CSF fistula were chosen for evaluation in addition to 78 patients who were randomly selected in 4 equally sized cohorts: male/female with small/large tumors. Preoperative CT scans were analyzed regarding petrous bone air cell volume, area of visible pneumatization at the level of the internal auditory canal (IAC), tumor grade, and sex. RESULTS: : Women developed nearly half as many CSF fistulas (2.7%) as men (5.2%). The mean volume of the petrous bone air cells was 10.97 mL (SD, 4.9; range, 1.38-27.25). It was significantly lower for women (mean, 9.23 mL; SD, 3.8) than for men (mean, 12.5 mL; SD, 5.28; P = .0008). The mean air cell volume of CSF-fistula patients was 13.72 mL (SD, 5.22). The difference concerning the air cell volume between patients who developed CSF fistulas and patients from the control group was significant (P = .0042). There was a significant positive correlation between the air cell volume and the area of pneumatization in one CT slide at the level of the IAC. CONCLUSION: The higher incidence of CSF fistulas in men compared with women can be explained by means of differently pneumatized petrous bones. A high amount of petrous bone pneumatization has to be considered as a risk factor for the development of postoperative CSF fistula after vestibular schwannoma surgery.

Cerebrospinal fluid leak with recurrent meningitis following tonsillectomy.

The authors report an unusual case of bilateral large petrous apex cephaloceles in a 14-year-old boy with a history of recurrent meningitis. Although these lesions are rare and usually asymptomatic, surgical correction is recommended if they are associated with a persistent CSF leak. In this patient, the extensive bilateral cranial defects were not adequately treated by an intracranial approach alone. Repair of a defect in the posterior pharyngeal wall, the site of a prior tonsillectomy, ultimately resulted in repair of the CSF fistula.

Asymmetric agenesis of the mastoid antrum in a neonate.

The authors report a case of asymmetric development of the mastoid antrum in a neonate. The lack of mastoid development most likely represents a congenital maldevelopment. Agenesis of the mastoid antrum has surgical implications, as failure to recognize its absence can result in disorientation during surgery, with potential to injure adjacent structures.

Facial diplegia revealing ventriculoperitoneal shunt failure in a patient with Crouzon syndrome. Case report.

The authors report on the case of a 15-year-old boy with Crouzon syndrome (CS) who presented with headache and facial diplegia. He had undergone several craniofacial interventions and a posterior fossa decompression for tonsillar herniation caused by the CS. A ventriculoperitoneal (VP) shunt had been inserted for hydrocephalus. Emergency computed tomography (CT) disclosed slight dilation of the ventricular cavities compared with their appearance on a baseline CT scan. Magnetic resonance imaging showed a deformed brainstem but no compression at the occipital foramen; there was no apparent explanation for the facial diplegia. The neuroophthalmological examination revealed neither papilledema nor oculomotor palsy. Electromyography confirmed incomplete peripheral facial diplegia. The patient underwent emergency shunt revision, during which complete obstruction of the ventricular catheter and severe cerebrospinal fluid hypertension were found. After surgery, cranial hypertension symptoms completely resolved and the facial diplegia improved slowly with a persistent and incomplete right superior facial palsy. Cranial 3D CT scanning reconstructions and brain magnetic resonance imaging demonstrated severe petrous bone distortion that could have been responsible for direct stretching injuries on the facial nerves at the level of the internal acoustic meatus. The present case represents the first reported occurrence of VP shunt failure as revealed by a facial palsy; the authors discuss the pathophysiology of facial palsy in intracranial hypertension.