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EMERGENCY CASEBOOKS

Tension pneumocephalus attributable to anethmoid osteoma presenting as a stroke inevolution: an unusual presentation

D C Bramley, S Ghosh

A 63 year old white man presented to the acci-dent and emergency department with a 24hour history of gradual onset of mild weaknessof his left upper limb, which progressed toinvolve his left lower limb. There was nohistory of any other CNS symptoms. He also

stated that the paresis varied with posturebeing worse on standing and sitting, while itwas relieved by lying down; it was alsoassociated with a noticeably diminished short-term memory over the past few weeks. Clinicalexamination confirmed a mild left hemiparesis(grade 4/5), with brisk reflexes and an equivo-calplantar response on the left. The rest of theexamination was unremarkable: he was normo-tensive, no carotid bruits were auscultated andthe fundi were normal. Haematological andbiochemical investigations were normal. Adiagnosis of a progressive cerebrovascular acci-dent (CVA) was made and he was admitted tohospital for further observation.

Over the next few days, his hemiparesisslightly worsened, and routine computed tom-ography was carried out four days later.Routine axial sections (fig 1) revealed a 5 cmdiameter pneumocephalus, and a mass withirregular calcification was noted arising fromthe base of skull in the right ethmoid sinuses(fig 2), encroaching on to the orbit. He wastransferred to the regional ENT/neurosurgicalcentre, where a surgical intervention wasdecided upon. He underwent a simultaneouslateral rhinotomy and bilateral frontal crani-otomy with an osteoplastic flap. A completeexcision of his osteoma was performed, apartfrom a small area near the orbital apex. Some40 ml of air were found trapped intracranially,and the osteoma was associated with multiplemucoceles, which was responsible for theirregular appearance on computed tomogra-phy. His skull base defect was repaired with afascia lata graft from his thigh. He made anuneventful recovery and his paresis improvedimmediately. His only persistent neurologicaldeficit is anosmia. Subsequent histopathologi-cal examination confirmed the diagnosis of anosteoma, with dense trabeculae and littleevidence of osteoblastic activity.

Primary osteomas of the ethmoid sinusesare rare tumours, and spontaneous pneumo-

cephalus is an unusual complication. Theyhave been known to present acutely with fits,headaches, dementia,1 cerebral abscesses,2 andacute cerebral hypertension.3 In this case thestriking postural hemiparesis was presumably

Figure 1 Coronal CT scan showing the osteoma withassociated mucocele.

Figure 2 Axial CT scan showing the frontal location ofthe pneumocephalus. Patient supine.

Emerg Med J 2001;18:317320 317

Department of

Otolaryngology, RoyalHallamshire Hospital,University of SheYeld,SheYeld

Correspondence to:Dr Bramley, 108 BurgoyneRoad, SheYeld S6 3QB, UK([email protected])

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attributable to the tension pneumocephaluscompressing the cerebral cortex. Interestingly,it is probable that the pneumocephalus wouldhave been apparent from initial presentationon a plain skull radiograph.

In conclusion, spontaneous pneumocephalusis one of the rare conditions that should be con-sidered in the diVerential diagnosis of raisedintracranial pressure and atypical neurologicalsymptoms including change with posture.

ContributorsMr A J Parker was responsible for the diagnosis and

management of this patient, and provided information regard-

ing this case, and also the more usual presentationsof osteomas. Mr A Panarese participated in the back-ground research involved in this paper and with editing thepaper.

Funding: none.

Conflicts of interest: none.

1 George J, Merry GS, Jellet LB, et al. Frontal sinus osteomawith complicating intracranial aerocoele. Aust N Z J Surg1990;60:668.

2 Holness RO,Attia E. Osteoma of the fronto-ethmoidal sinuswith secondary brain abscess and intracranial mucocele:

case report. [Letter]. Neurosurgery 1995;36:123738.3 Pennau D, Dubin J, Faivre J, et al. Acute intracranial hyper-tension. Pneumatocoele-osteoma of the frontal sinus. [InFrench]. Revue dOto-Neur-Opthalmologie 1976;48:5770.

Hallucal sesamoid bone stress fracture; 21stcentury club foot

R Singh, N Slater

Case report

A 24 year old woman complained of pain andswelling plantar surface of her right great toeafter spending many hours dancing in a nightclub. This was her principal social activity.Although tall, she wore high heels. Examina-tion revealed tenderness localised to the fibularsesamoid and radiography (fig 1) confirmed alongitudinal fracture of this bone. Symptomssettled rapidly with conservative treatmentincluding use of flat soled trainers.

Discussion

Tibial and fibular sesamoid bones occur withinthe tendon slips of flexor hallucis brevisbeneath the first metatarsal head; they increasethe mechanical advantage of this muscleduring the toe-oV phase of locomotion andmay also share weight bearing.1 Fractures andsesamoiditis, most commonly of the tibial sesa-moid, are seen in professional dancers2 andathletes,3 probably caused by compressiveforces between sesamoid and metatarsal headbut possibly by repeated tensile forces fromvigorous toe-oV activity.

High heels flex the first metatarsophalangeal

joint and increase compressive forces on thesesamoids. This, and many hours of vigorousdancing probably combined to cause the injuryreported here. Widespread use of recreationaldrugs that enhance mood and energy andmight persuade a person to ignore skeletal dis-comfort may also contribute to this clubfoot. Clubbing culture shows no signs ofabating and we believe this injury will berecognised increasingly in future with the acci-dent and emergency department as probablefirst site of presentation.

1 Yamaguchi Y. Biomechanical investigation of the sesamoidbones of the hallux. Journal of the Japanese Orthopaedic

Association 1993;67:21120.2 Quirk R. Common foot and ankle injuries in dance. Orthop

Clin North Am 1994;25:12333.3 Richardson G. Injuries to the hallucal sesamoids in the ath-

lete. Foot Ankle 1987;7:234.

Figure 1 Anteroposterior non-weight bearing radiograph

of the right forefoot showing a recent longitudinal fracture ofthe fibular sesamoid.

318 Emergency casebooks

Department ofOrthopaedic andTrauma Surgery, The

Maidstone Hospital,Maidstone, Kent,ME16 9QQ, UK

Correspondence to:

Mr Slater ([email protected])

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Tension pneumothorax: a diYcult diagnosis

B L Watts, M A Howell

A 65 year old man was brought into the resus-citation room in cardiac arrest. Forty five min-utes earlier he had become short of breathbefore collapsing. The only other historyavailable was that he had undergone a leftpneumonectomy several years previously forcarcinoma of the lung but was thought to havemade a full recovery. Basic life support wasperformed by the patients work colleaguesand when the paramedics arrived the patientwas asystolic. He was treated according toAdvanced Life Support (ALS) guidelines1 andbriefly regained a cardiac output before hearrested again, this time in electro-mechanicaldissociation (EMD). A total of 8 mg ofadrenaline (epinephrine) was given by the

paramedics. On arrival at the accident andemergency department the patient was intu-bated and cannulated. The endotracheal tubeposition was checked and breath sounds wereaudible on both sides of the chest. There waslittle movement of the left side of the chest andthe trachea was deviated towards that side;there were scars consistent with his previoussurgery over the left chest wall. The right sideof the chest was hyperexpanded.

The patient was in EMD and the ALS pro-tocol was followed. Intravenous fluids werestarted and after two further 1 mg doses ofadrenaline there was a return of spontaneouscirculation. Chest radiography was performed.At this time there was no spontaneous respira-tion and the highest oxygen saturation re-corded by pulse oximetry was 80%. Thepatient briefly arrested again (EMD) butresponded to a single 1 mg bolus of adrena-line.

The chest radiograph showed a right sidedpneumothorax (fig 1). A 14G intravenous can-nula was inserted into the right secondintercostal space in the mid-clavicular line anda clear hiss of air was heard as the needle was

withdrawn. The patients clinical conditionimmediately improved with oxygen saturationreading 99% on oxygen via the endotrachealtube. An intercostal tube was inserted (fig 2)and the patient was transferred to the intensivecare unit where he unfortunately died approxi-mately 30 hours after admission. A postmor-tem examination revealed that the cause of theright pneumothorax was a ruptured bulla; thecause of death was cerebral hypoxic damage.

A tension pneumothorax occurs when a oneway valve is created between the lung and thepleura.2 This leads to an accumulation of airwithin the pleural cavity during each respira-tory cycle, with a consequent increase inintrathoracic pressure. Eventually the ipsilat-

eral lung collapses and the mediastinum is dis-placed away from the aVected side. Venousreturn is impeded and cardiac arrest ensues.ALS teaches us to consider tension pneumo-thorax in patients who are in EMD cardiacarrest and to seek the classic findings of adeviated trachea and reduced breath sounds insuch patients. In our patient the trachea wasdeviated to the left and the right side of thechest was hyperexpanded but these clinicalfindings were anticipated and thought to besecondary to his pneumonectomy. Breathsounds were audible bilaterally, presumablybecause of some residual lung tissue on theleft side. It was not until the chest radiographbecame available that the diagnosis of a rightpneumothorax was realised. Although thedeviated trachea and mediastinal shift wereagain probably secondary to pneumonectomy(these features remained on the post-intercostal drain), the patients clinical con-dition suggested that the pneumothorax wasunder tension and this was confirmed byneedle thoracostomy. This is clearly a veryunusual situation but serves to remind us thatprevious pneumonectomy does not preclude a

Figure 1 Chest radiograph showing a r ight sidedpneumothorax and mediastinum shifted towards the left.There is a white out of the left lung field.

Figure 2 Chest radiograph after intercostal drain insertionshowing the reinflated right lung. The mediastinum remainsshifted towards the left.

Emergency casebooks 319

Accident andEmergency

Department, QueenAlexandra Hospital,Southwick Hill Road,Cosham, Portsmouth,Hampshire PO6 3LY,

UK

Correspondence to:Dr Watts([email protected])

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tension pneumothorax on the opposite side ofthe chest. Finally, if such a diagnosis is consid-ered, the correct course of action is immediatedecompression before obtaining radiologicalconfirmation.

1 Resuscitation Council (UK). Advanced life support manual.3rd ed. London: 1998.

2 Driscoll PA, Gwinutt CL, Graham TR. Chest and cardiactrauma. In: Skinner D, Swain A, Peyton R, et al, eds. Cam-bridge textbook of accident and emergency medicine.Cambridge: Cambridge University Press, 1997:538.

An unusual cause of hip pain in a childM Hynes, F Lam

An 11 year old boy presented to the accidentand emergency department complaining of lefthip pain after a fall from his skateboard. Apartfrom a mild restriction of hip movementcaused by pain, physical examination and apelvic radiograph in the AP view were unre-markable. He was discharged home withsimple analgesia.

He presented again two weeks later with

worsening pain and a limp. Examinationrevealed exquisite tenderness in his glutealmuscles with a markedly reduced range ofmovement. Repeat pelvic radiographs includ-ing AP and frog lateral views were performedshowing a calcified mass in the abductormechanism of his left hip (fig 1). In view of theunresolving pain, magnetic resonance imagingwas performed showing high signalling withinthe mass with distortion of the adjacentmuscular structure associated with marked softtissue swelling and an eVusion in the hip joint(fig 2). This raised the suspicion of a tumour.Consequently, a computed tomography guidedbiopsy was performed showing histologicalfeatures of reactive new bone formation,

suggestive of myositis ossificans.1 The patientwas subsequently treated with indomethacinand symptoms resolved a few weeks later.

Myositis ossificans is the formation ofmature bone outside the skeleton. Although itis an entirely benign condition, it isnevertheless an important condition because inits early stages presentation may be diYcult todistinguish both clinically and radiologicallyfrom a soft tissue tumour such as rhabdomy-osarcoma, which is the commonest soft tissuesarcoma in this patients age group.2 Other dif-ferential diagnoses would include a calcifyinghaematoma, slipped capital femoral epiphysisand septic arthritis. The other important

learning point is that any child with a persistinglimp should be evaluated radiologically withtwo views including a frog lateral because con-ditions such as slipped capital femoral epiphy-sis are easily missed on the AP view alone.

1 Hanquinet S, Ngo L, Anooshiravani M, et al. Magneticresonance imaging helps in the early diagnosis of myositisossificans in children. Pediatric Surgery International1999;15:2879.

2 de Almeida MM,Abecassis N, Almeida MO, et al. Fine nee-dle aspiration cytology of myositis ossificans: a case report.Diagn Cytopathol1994;10:413.

Figure 1 Calcified mass in the abductor mechanism of theleft hip.

Figure 2 Abnormal high signalling within the mass withmarked surrounding soft tissue swelling.

320 Emergency casebooks

Department ofTrauma andOrthopaedics, Chase

Farm Hospital,Enfield, Middlesex

Correspondence to:Mr Lam, 4 Middlefield, St

Johns Wood, LondonNW8 6NE([email protected])

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doi: 10.1136/emj.18.4.3192001 18: 319-320Emerg Med J

B L Watts and M A HowellTension pneumothorax: a difficult diagnosis

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