Meningiomas invading the temporal bone with extension to the neck

Meningiomas are the second largest group of brain tumors after gliomas. They account for 13 to 18 per cent of all primary intracranial neoplasms. The majority occur in the cerebral chamber; only 8 to 9 per cent are located in the cerebellar chamber. Meningiomas are hamartomatous, not truly neoplastic tumors, which arise from dural fibroblasts and particularly from arachnoid cells that tend to cluster around the tips of the arachnoid villi. Their preferential sites correspond closely with the locations where arachnoid villi are most frequently encountered, namely, along the major venous sinuses and their contributory veins, at the foramina of exit of the cranial nerves, and where arachnoid cell clusters are found within the trunk or the perineural sheaths of cranial nerves within or adjacent to the basal foramina. Of all intracranial meningiomas, 20 per cent eventually develop an extracranial extension. These extracranial extensions project, in order of decreasing frequency, to 1) the orbit, 2) the external table of the calvaria, 3) the nasal cavity and paranasal sinuses, and 4) the parapharyngeal (cervical) space. Once a meningioma has gained access to the temporal bone, its tendency to extend beyond the confinements of the skull increases to 43 per cent. The most frequent pathway is through the jugular and lacerate foramina into the parapharyngeal space, where it may manifest as a nasopharyngeal, oropharyngeal, retromaxillary, retromandibular, or cervical neck mass. A meningioma in the parapharyngeal area can represent 1) an extracranial extension of a primary intracranial tumor, 2) a neoplasm arising in the jugular foramen, 3) a neoplasm originating from an arachnoid cell cluster within the trunk of a cranial nerve or its perineural sheaths within or near a neural foramen, or 4) a metastasis to a cervical lymph node from a primary intracranial meningioma. Meningiomas extending to the neck are unique because of their tendency toward extracranial expansion, higher incidence of local recurrence, multicentric growth, and frequent combination with other neoplasms of the central nervous system. They are frequently an expression of the central form of neurofibromatosis (von Recklinghausen's disease).     

Recurrent extracranial sinonasal meningioma presenting 27 years after complete surgical eradication of right frontal meningioma

A 79-year-old man presented to our department with nasal obstruction and postnasal drip. On examination he had unusual bilateral nasal polyps, which were histologically diagnosed as meningioma. Twenty-seven years earlier he had undergone successful removal of a right frontal meningioma. A CT scan performed 7 years after his primary surgery had shown complete excision with no evidence of recurrence. Extracranial meningiomas are rare tumours and are usually extensions from an intracranial mass lesion. We document what we believe to be the first case of an extracranial meningioma, presenting as nasal polyps, 27 years after successful surgical eradication of the primary lesion.     

Recurrent extracranial sinonasal meningioma presenting 27 years after complete surgical eradication of right frontal meningioma

A 79-year-old man presented to our department with nasal obstruction and postnasal drip. On examination he had unusual bilateral nasal polyps, which were histologically diagnosed as meningioma. Twenty-seven years earlier he had undergone successful removal of a right frontal meningioma. A CT scan performed 7 years after his primary surgery had shown complete excision with no evidence of recurrence. Extracranial meningiomas are rare tumours and are usually extensions from an intracranial mass lesion. We document what we believe to be the first case of an extracranial meningioma, presenting as nasal polyps, 27 years after successful surgical eradication of the primary lesion.     

Presentation of rhinosinugenic intracranial abscesses

Intracranial abscesses secondary to rhinosinugenic disease are uncommon and the incidence is poorly documented. It is generally believed that individuals at risk of developing this complication can be identified by presenting clinical features. A ten year retrospective Scottish national survey 1976-1985 of intracranial abscesses was carried out. Clinical and or radiological evidence of nasal/paranasal aetiology in abscesses localised to the frontal lobe, extradural or subdural spaces allowed 23 surgery or autopsy confirmed abscesses to be classified as rhinosinugenic. 12 abscesses occurred in individuals aged 0-19 years, two in patients with risk factors for intracranial spread, 8 of 11 adults had similar predisposing features (p less than 0.01). This is a rare complication and individuals at risk in the first two decades of life can seldom be identified prospectively on clinical grounds.     

A case of nasal glioma in a new-born infant

We report a 1 day old girl with a nasal mass that was diagnosed as an intranasal glioma. The tumor mass was noted to be localized laterally from, and based along, the inferior turbinate. Nasal glioma is a developmental abnormality of neurogenic origin with no malignant potential. An intranasal mass requires careful rhinological, neurological and radiological examinations. With adequate initial removal, excisional biopsy usually allows complete recovery. A frontal craniotomy approach is preferred for those patients who have nasal glioma with an intracranial connection. With no evidence of an intracranial connection, a conservative extracranial approach is recommended.     

Extracranial and intracranial meningiomas

Meningiomas constitute about 18% of primary intracranial tumors, and they are rarely observed in patients under 30 years of age. In this study, we present the case of a 17-year-old patient who was first seen for a right cervical mass. Further investigation revealed that a meningioma of the posterior cranial fossa had invaded the temporal bone, the infratemporal fossa and the right parapharyngeal region and was at the origin of that cervical mass. This intra- and extracranial meningioma was completely resected in two stages with very satisfactory results. We have reviewed the literature pertaining to the extracranial extensions of meningiomas originating in the posterior fossa.     

Nasopharyngeal glioma in a new-born girl

Nasal gliomas are uncommon tumours of neurogenic origin that occur sporadically. They are diagnosed with MRI and a preoperative biopsy, and surgery is the treatment of choice. Most of the gliomas emerge from the nasal cavity, but only a few cases of nasopharyngeal gliomas have been reported. We present one case of a nasopharyngeal glioma and two cases of nasal gliomas.     

The Evaluation of Middle Ear Meningiomas Using Computerized Axial Tomography

Meningiomas localized within the middle ear and mastoid which have no intracranial component are rare tumors. Three patients with meningiomas which were thought to involve only the middle ear were treated surgically, were followed for two to six years and were thought to have been cured. However, when computerized axial tomography became clinically available, these patients were examined using this radiographic technique. Unexpectedly, all three patients were found to have a large intracranial meningiomatous extentiion, A review of the literature reveals only 13 primary meningiomas; these case reports are summarized. It was noted that definitive tests for an intracranial extension of the meningioma were performed in only 2 of the 13 cases. Therefore, in view of our recent clinical experience, it is recommended that a patient presenting with a middle ear meningioma should have a computerized axial tomographic examination of the head to detect the possible presence of a clinical silent intracranial involvement.     

ACTH-producing paraganglioma of the paranasal sinuses

Paragangliomas are tumours of neuroectodermal origin and hormonally active in rare instances.They are very unusual in the paranasal sinuses. We report on the first case--as far as we know--of a recurrent nasal paraganglioma, which started to produce ACTH after a period of ten years and resulted in Cushing's syndrome. Resection of the tumour normalised ACTH and cortisol secretion.     

Meningioma of the internal auditory canal with extension into the vestibule

Meningiomas account for approximately 18 to 19 per cent of all brain tumours. Although they can arise in numerous locations, meningiomas of the internal auditory canal (IAC) are rare. Most tumours that originate in the IAC are schwannomas of the VIIIth cranial nerve (acoustic neuromas). We report a case of a meningioma which appears to originate from the IAC and extends into the vestibule. The clinical findings and the radiographical features of meningiomas of the IAC are similar to those of acoustic neuromas. Pre-operative differentiation between acoustic neuromas and meningiomas of the IAC may be difficult.     

Spontaneous extradural hematoma as a presentation of sinusitis: case report and literature review

Spontaneous extradural hematoma is rarely mentioned in literature as intracranial complications of sinusitis. The authors presented a girl with spontaneous extradural hematoma secondary to pansinusitis and reviewed the literature. In a child with spontaneous extradural hematoma without a history of head trauma, sinusitis should be excluded.     

A case of solitary neurofibroma of the nasal dorsum: resection using an external rhinoplasty approach

A 7-year-old girl had suffered from progressive swelling of the nasal dorsum over 2 years. Computed tomography and magnetic resonance imaging showed a large soft tissue density in the nasal dorsum. Tc-99m DTPA cisternography and brain SPECT showed a restricted mass in the nasal dorsum without intracranial connection. The mass was resected using an external rhinoplasty approach, and the pathologic diagnosis was of neurofibroma. Furthermore, the nasal dorsum was identified as the origin of the neurofibroma without the stigma of neurofibromatosis. Here, we present this case and discuss the clinical and pathological aspects of neurofibroma arising in the nasal dorsum.     

Primary external auditory canal meningioma: Case report and review of the literature

Meningiomas are tumors that arise from arachnoid cells attached to both the pia mater and the inner portion of the arachnoid. They are common intracranial tumors, representing 12-25% of intracranial neoplasms. Intracranial meningiomas can spread extracranially to involve surrounding structures, including the ear and temporal bone. Ectopic meningiomas, described as primary meningiomas with no intracranial involvement, are rare. We describe a case of a primary external auditory canal meningioma with no evidence of intracranial involvement. We present pre-operative imaging findings proving no intracranial involvement prior to surgical intervention. A literature review of this uncommon clinical entity is presented and a discussion regarding its prognosis and treatment is reviewed.     

Meningioma in the parotid region

Meningiomas occurring ectopically in the neck are exceptional. We report two patients who presented as parotid and parapharyngeal masses and analyze them along with 27 previously reported cases. Typical patients present with parotid or parapharyngeal masses and cranial nerve palsies. Meningioma is not considered in differential diagnosis. The tumor is an extension of an unsuspected intracranial mass, occasionally with associated multiple meningiomas or other neurogenic tumors. Ectopic meningiomas should be considered in patients with parotid and parapharyngeal masses, particularly those with cranial nerve deficits; jugular foramen syndrome is most characteristic. Associated occult intracranial and temporal bone tumors and the cranial form of neurofibromatosis should be suspected. Treatment of cervical meningiomas is excision. The most important aspect of intracranial-extracranial lesions is recognition and treatment of the intracranial portion.     

Metachronous adenocarcinoma of the maxillary sinuses: a rare entity

Malignant tumours of the nasal cavities and paranasal sinuses are uncommon. They constitute less than one per cent of all tumours and less than three per cent of head and neck tumours. Although multiple primary carcinomas of the aerodigestive tract are commonly reported, metachronous maxillary sinus carcinomas are rare. To date, all of these cases reported are of squamous cell origin. The incidence of metachronous maxillary carcinoma involving both sinuses is in the range of 1.4 per cent amongst patients with maxillary carcinoma. We present the first reported case, to our knowledge, of a patient with metachronous adenocarcinoma of the maxillary sinus.     

Mini-craniotomy for management of csf otorrhea from tegmen defects.

CSF otorrhea arising from defects in the tegmen and middle fossa dura may be congenital or acquired. It may be spontaneous or secondary to trauma, chronic ear disease, tumor or surgical treatment. In the six cases presented, the tegmen defect and associated CSF leak were secondary to chronic ear disease in two cases, to mastoid surgery in two cases, to temporal bone fracture and congenital origin in one case each. The successful management of these patients utilizing a mini-craniotomy in conjunction with mastoid surgery is described. Mini-craniotomy facilitates precise extradural, intracranial placement of an autogenous graft over the tegmen defect which can be technically difficult in the transmastoid approaches, yet avoids the morbidity and potential complications of a full middle fossa craniotomy. It does not significantly add to the length of the mastoid procedure or its complications.     

Primary meningioma of the nasopharynx: case report and review of ectopic meningioma

Meningiomas not uncommonly spread outside the central nervous system, but primary extracranial meningiomas are much less common, the sites described including the orbit, the calvarium, the neck, the temporal bone and the paranasal sinuses. Reported here is the first instance of extracranial meningioma of the nasopharynx. The histological appearance of meningiomas is diverse, and in ectopic sites can be mistaken for malignant epithelial tumors, as happened here initially. The tumor was excised via a transpalatal flap using an intracapsular debulking approach borrowed from the armamentarium of the intracranial surgeon. Prolonged follow-up with interval CT scans are recommended in patients with apparent ectopic meningioma, in case undemonstrable intracranial disease later becomes manifest.     

Trilobed meningioma: ampulla of posterior semicircular canal, internal auditory canal, and cerebellopontine angle

Meningiomas rarely arise from or remain limited to the temporal bone. When the diagnosis of temporal bone meningioma is made, it is mandatory to investigate the possibility of an intracranial component. Computerized axial tomography with contrast enhancement is of limited value in detecting small tumors adjacent to the temporal bone or within the internal auditory canal. If the computerized tomogram is normal, a positive contrast posterior fossa myelogram is indicated. The pitfall of depending solely upon computerized tomography to detect intracranial extension became clear in the evaluation of a patient found to have an unusual trilobed meningioma.     

Surgical approaches for nasal dermal sinus cysts

Nasal midline masses of ectodermal origin include nasal dermoids (ND) and nasal dermal sinus cysts (NDSC). NDSC are characterized by an intracranial-extradural extension, while ND are limited to the nasal dorsum, medial canthus, or glabella without intracranial extension. We report our experience in 11 NDSC patients. The goal of this study is to present the management including surgical technique for NDSC and compare it with the literature. Because a transfacial approach for NDSC with vertical incision caused visible scarring in two out of three patients, we applied a new surgical approach in four patients. This approach consisted of a simple excision and mobilisation of the pit while the proximal part is resected using a coronal transfrontal approach. The relation of the nasal fistula to the nasal bone is essential considering osteotomy. Disruption of the bony cartilaginous junction of the nasal dorsum must be prevented to avoid later growth impairment of the nose. There was no recurrence of NDSC in all 7 operated patients after a mean follow-up of 3.9 years (range 0.5-7.2 years).     

Ectopic meningioma: a case report with a literature review

Ectopic (extradural) meningiomas that do not originate from either the optic fascicle or the intracranial meninges are exceedingly rare. A patient with an ectopic meningioma in the external auditory canal and mastoid was treated in our unit. The world literature of the last 20 years was reviewed.