Spontaneous otogenic pneumocephalus managed with the middle fossa approach

Abstract

Objectives: Otogenic pneumocephalus is an uncommon entity usually caused by otologic surgery, trauma, tumor, or infection. Spontaneous pneumocephalus caused by barotrauma is extremely rare. We surveyed the literature and describe a case report of otogenic pneumocephalus from barotrauma managed with a middle fossa craniotomy. Methods: A literature review was performed by querying MEDLINE from 1966 to the present by querying the MeSH heading “Pneumocephalus” and filtering the results for cases involving the ear or mastoid. Case report: A 60-year-old man had onset of hearing loss, aural fullness with a “gurgling” sensation, and roaring tinnitus in the right ear following a transatlantic flight. Symptoms persisted for 3 months. The patient underwent CT and MRI scanning, which revealed air in the ventricular system, a right temporal lobe cyst, and a thinned tegmen. A clear middle ear effusion, air-bone gap of 30 dB, and a left superior homonymous quadrantanopsia were present. The patient underwent an exploratory middle fossa craniotomy. Results: At surgery, the middle fossa floor demonstrated multiple bony defects and there were several small holes in the dura. A multilayered repair of this area was undertaken using temporalis fascia, bone chips, synthetic dura, and fibrin glue. The literature review revealed 3 similar cases in the neurotologic literature. Conclusion: Spontaneous otogenic pneumocephalus remains an uncommon finding. Anatomic defects in the floor of the middle cranial fossa contribute to the development of this rare entity. Neurotologic consultation should be obtained. In selected instances, middle fossa craniotomy and repair of the dural and bony defects may be required.