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Journal of Radiology Case Reports

Craniocervical Pneumatization

Case Report

Alan James Quigley1*, Helen Shannon2

Radiology Case. 2013 Aug; 7(8):27-33 :: DOI: 10.3941/jrcr.v7i8.1444

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1. Department of Radiology, Aberdeen Royal Infirmary, Aberdeen, UK
2. Department of Radiology, Raigmore Hospital, Inverness, UK

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  ABSTRACT
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Craniocervical bony pneumatization is a rare finding, with limited numbers of cases reported in the literature. It is thought to be linked to Eustachian tube dysfunction and a ball valve mechanism, and has a link with recurrent Valsalva maneuvers. We report a case of pneumatization of the occiput, atlas (C1) and axis (C2) in a patient with extensive ENT (Ear, Nose and Throat) surgical history who presented following a fall. Plain film, CT and MRI images are presented.








  CASE REPORT
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A 45-year-old man presented following a fall while hill-walking. He had hyperextended his neck but had not injured his head. He complained of developing dysphagia and a sensation of throat swelling after the fall. He also had nausea with vomiting and pain in the left side of his neck and ear. On examination, no neurological deficit was elicited but he was noted to have new vocal hoarseness. His past medical history revealed an extensive previous ENT history. Over the previous 30 years he had recurrent problems with bilateral chronic suppurative otitis media and Eustachian tube dysfunction. Previous surgeries included a right tympanoplasty, right meatoplasty, left myringotomy and grommet insertion and left meatoplasty. Most recently two years ago, he had a tonsillectomy for recurrent tonsillitis and right quinsy.

Plain film radiographs of the cervical spine revealed pneumatization of the occiput, C1 and spinous process of C2, with a small amount of gas in the adjacent soft tissues (Fig. 1 Preview this figure

Figure 1: Conventional Radiography
45 year old male with craniocervical pneumatization. Lateral plain radiograph of the base of skull and upper cervical vertebral spine showing pneumatization of the occiput, C1 and spinous process of C2 with a small amount of adjacent soft tissue air (white arrows) (protocol: 73 kVp, 10 mAs).
and Fig. 2 Preview this figure
Figure 2: Conventional Radiography
45 year old male with craniocervical pneumatization. Odontoid process plain AP radiograph showing pneumatization of C1 lateral masses (white arrows) (protocol: 70 kVp, 8 mAs).
). No obvious fracture was identified. Multislice Computed Tomography (CT) of the skull base and cervical spine was performed using a GE Lightspeed VCT (64-slice). This showed extensive pneumatization of the occiput, C1 and posterior arch/spinous process of C2 (Fig. 3 Preview this figure
Figure 3: Computed Tomography
45 year old male with craniocervical pneumatization. Series of axial non-contrast CT images (GE Lightspeed VCT, protocol: 120kV, 1mAs, 1.25mm slices, non-contrast, dose 506mGy) showing the extensive pneumatization of the occiput, C1 and posterior arch of C2. Continuous aeration from the left mastoid air cells into the apex of the left petrous temporal bone and left clivus can be seen (white arrows in 3a & 3b). Areas of fluid attenuation are seen within the pneumatized occiput (asterisks in 3a & 3b) and cervical vertebrae (broken white arrows in 3c & 3d).
a-d). Continuous aeration was noted from the left mastoid air cells into the apex of the left petrous temporal bone and left clivus. Fluid density was identified in some areas of the pneumatized bone. An apparent communication between the right occipital condyle and C1 was identified (Fig. 4 Preview this figure
Figure 4: Computed Tomography
45 year old male with craniocervical pneumatization. Non-contrast CT (GE Lightspeed VCT, protocol: 120kV, 1mAs, 2mm coronal reformats, non-contrast, dose 506mGy) showing pneumatization of C1 and the occiput with an apparent communication between the right occipital condyle and medial aspect of the right lateral mass of C1 (white arrow).
). Multiple locules of gas were noted in the soft tissues adjacent to the occiput and posterior arch of C1. The marked cortical thinning secondary to the degree of pneumatization as well as slight cortical irregularity of the posterior arch of C1 made an underlying fracture a possibility (Fig. 5 Preview this figure
Figure 5: Computed Tomography
45 year old male with craniocervical pneumatization. Axial non-contrast CT image images (GE Lightspeed VCT, protocol: 120kV, 1mAs, 1.25mm slices, non-contrast, dose 506mGy) showing air in the soft tissues adjacent to the posterior arch of C1 on the left side (white arrows), with cortical irregularity of the posterior arch indicating a possible fracture.
). A Magnetic Resonance Imaging (MRI) study was performed using a Philips Intera 1.5T. This revealed normal brain and cervical/upper thoracic spinal cord appearances. Fluid, corresponding to that seen in the CT, was identified within the occiput, posterior ring of C1 and spinous process of C2 (Fig. 6 Preview this figure
Figure 6: Magnetic Resonance Imaging
45 year old male with craniocervical pneumatization. MRI Axial (6a) & Sagittal (6b) T2 sequences (Philips Intera 1.5T, TR = 3658, TE = 120, slice thickness 3mm, non-contrast) of the base of skull, cervical spine and upper thoracic spine. Areas of increased T2 signal in the occiput and spinous processes of C1 and C2 in keeping with fluid within the areas of pneumatization (white arrows). Normal visualized spinal cord.
a & b).

An ENT review revealed no acute abnormality on examination. The patient was discharged after a few days. He continued to complain of neck discomfort and a subsequent CT was performed 3 months after the initial presentation. This revealed a reduction in the fluid in the occiput, atlas and axis, with the fluid replaced by gas. No new fracture was found. The previously noted cortical irregularity had resolved. There remained an unchanged small amount of gas in the adjacent soft tissues. This was not considered clinically significant given the absence of underlying fracture.

  DISCUSSION
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Human bony pneumatization occurs normally in the paranasal sinuses and middle ear. Bony pneumatization has been shown to be present as early as 24 weeks gestation [1], but radiographically is visible only after birth. There are three stages of pneumatization; infantile (birth to 2 years), transitional (from 2 to 5 years) and adult [2]. Once the adult stage has been reached, pneumatization should cease. Temporal bone pneumatization has been divided into 5 regions; the middle ear, mastoid, perilabyrinthine, petrous apex and accessory [3]. The extent of the pneumatization of the temporal bone can vary greatly between individuals.

In this case report, we show an example of craniocervical pneumatization. First reported in 1940 [4], hyperpneumatization of the occipital bone is a very rare condition with less than 20 cases in the literature to the best of our knowledge [5-16]. Even rarer is craniocervical pneumatization, pneumatization of both the occiput and cervical vertebrae [5,10-14,17]. As in our case, craniocervical pneumatization exhibits a male predominance in the reported cases.

Various theories have been proposed for the cause. The most commonly quoted is a ball valve mechanism where air forced up the Eustachian tube is trapped and gradually leads to enlargement of the sinuses with extension into the occiput [13,15,16]. Triggers for this include recurrent Valsalva maneuvers [5,11,13,15,16], excessive coughing [14] and recurrent high-altitude travel [8]. Our patient had an extensive ENT history although didn`t describe any history of recurrent Valsalva maneuvers. In some of those cases with craniocervical pneumatization, apparent communications are visualized between the pneumatized occipital condyles, atlas and axis [10,11]. In our case, communication was seen between the right occipital condyle and medial aspect of the right lateral mass of C1. However, no communication was seen between the atlas and axis in our case, despite axis aeration.

Commonly reported symptoms in patients with craniocervical pneumatization include headache, vertigo, tinnitus, nausea, a feeling of fullness in the temporal region or a palpable swelling. Tinnitus has also been reported in patients with extensive temporal bone pneumatization [18]. Due to the cortical thinning associated with the pneumatization, patients are at increased risk of fractures from minor trauma [5,6,7]. Valsalva maneuver has also been reported as a cause of fracture [5,11]. Fractures are reported as painless but it is the accumulation of gas in the soft tissues that can cause symptoms [5].

Some studies have shown regression of the pneumatization following treatment of the Eustachian tube dysfunction by tympanic drainage or asking the patient to reduce the number of Valsalva maneuvers they perform [11,14,16]. Follow-up CT examinations have shown healing of fractures and new bone formation and sclerosis, with pneumatization regression. At the sites of communication between the occipital condyles and lateral masses of C1, assimilation may be seen on the follow-up examinations [5].

In conclusion, craniocervical pneumatization is a rare condition with few cases reported in the literature. Thought to be linked to Eustachian tube dysfunction and a ball valve mechanism, it has a link with recurrent Valsalva maneuvers and high-altitude travel.

  TEACHING POINT
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While a rare condition, a finding of craniocervical pneumatization should alert the reporting radiologist to the possibility of Eustachian Tube dysfunction and a relevant ENT history should be sought. In a history of even only minor trauma, there is increased risk of fracture given the marked cortical thinning, and special care should be taken for subtle fractures when reporting.








  FIGURES
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Display figure 1 in original size

Figure 1: 45 year old male with craniocervical pneumatization. Lateral plain radiograph of the base of skull and upper cervical vertebral spine showing pneumatization of the occiput, C1 and spinous process of C2 with a small amount of adjacent soft tissue air (white arrows) (protocol: 73 kVp, 10 mAs).

Figure 1: Conventional Radiography (Open in original size)
45 year old male with craniocervical pneumatization. Lateral plain radiograph of the base of skull and upper cervical vertebral spine showing pneumatization of the occiput, C1 and spinous process of C2 with a small amount of adjacent soft tissue air (white arrows) (protocol: 73 kVp, 10 mAs).

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Display figure 2 in original size
Figure 2: 45 year old male with craniocervical pneumatization. Odontoid process plain AP radiograph showing pneumatization of C1 lateral masses (white arrows) (protocol: 70 kVp, 8 mAs).

Figure 2: Conventional Radiography (Open in original size)
45 year old male with craniocervical pneumatization. Odontoid process plain AP radiograph showing pneumatization of C1 lateral masses (white arrows) (protocol: 70 kVp, 8 mAs).

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Display figure 3 in original size
Figure 3: 45 year old male with craniocervical pneumatization. Series of axial non-contrast CT images (GE Lightspeed VCT, protocol: 120kV, 1mAs, 1.25mm slices, non-contrast, dose 506mGy) showing the extensive pneumatization of the occiput, C1 and posterior arch of C2. Continuous aeration from the left mastoid air cells into the apex of the left petrous temporal bone and left clivus can be seen (white arrows in 3a & 3b). Areas of fluid attenuation are seen within the pneumatized occiput (asterisks in 3a & 3b) and cervical vertebrae (broken white arrows in 3c & 3d).

Figure 3: Computed Tomography (Open in original size)
45 year old male with craniocervical pneumatization. Series of axial non-contrast CT images (GE Lightspeed VCT, protocol: 120kV, 1mAs, 1.25mm slices, non-contrast, dose 506mGy) showing the extensive pneumatization of the occiput, C1 and posterior arch of C2. Continuous aeration from the left mastoid air cells into the apex of the left petrous temporal bone and left clivus can be seen (white arrows in 3a & 3b). Areas of fluid attenuation are seen within the pneumatized occiput (asterisks in 3a & 3b) and cervical vertebrae (broken white arrows in 3c & 3d).

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Display figure 4 in original size
Figure 4: 45 year old male with craniocervical pneumatization. Non-contrast CT (GE Lightspeed VCT, protocol: 120kV, 1mAs, 2mm coronal reformats, non-contrast, dose 506mGy) showing pneumatization of C1 and the occiput with an apparent communication between the right occipital condyle and medial aspect of the right lateral mass of C1 (white arrow).

Figure 4: Computed Tomography (Open in original size)
45 year old male with craniocervical pneumatization. Non-contrast CT (GE Lightspeed VCT, protocol: 120kV, 1mAs, 2mm coronal reformats, non-contrast, dose 506mGy) showing pneumatization of C1 and the occiput with an apparent communication between the right occipital condyle and medial aspect of the right lateral mass of C1 (white arrow).

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Display figure 5 in original size
Figure 5: 45 year old male with craniocervical pneumatization. Axial non-contrast CT image images (GE Lightspeed VCT, protocol: 120kV, 1mAs, 1.25mm slices, non-contrast, dose 506mGy) showing air in the soft tissues adjacent to the posterior arch of C1 on the left side (white arrows), with cortical irregularity of the posterior arch indicating a possible fracture.

Figure 5: Computed Tomography (Open in original size)
45 year old male with craniocervical pneumatization. Axial non-contrast CT image images (GE Lightspeed VCT, protocol: 120kV, 1mAs, 1.25mm slices, non-contrast, dose 506mGy) showing air in the soft tissues adjacent to the posterior arch of C1 on the left side (white arrows), with cortical irregularity of the posterior arch indicating a possible fracture.

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Display figure 6 in original size
Figure 6: 45 year old male with craniocervical pneumatization. MRI Axial (6a) & Sagittal (6b) T2 sequences (Philips Intera 1.5T, TR = 3658, TE = 120, slice thickness 3mm, non-contrast) of the base of skull, cervical spine and upper thoracic spine. Areas of increased T2 signal in the occiput and spinous processes of C1 and C2 in keeping with fluid within the areas of pneumatization (white arrows). Normal visualized spinal cord.

Figure 6: Magnetic Resonance Imaging (Open in original size)
45 year old male with craniocervical pneumatization. MRI Axial (6a) & Sagittal (6b) T2 sequences (Philips Intera 1.5T, TR = 3658, TE = 120, slice thickness 3mm, non-contrast) of the base of skull, cervical spine and upper thoracic spine. Areas of increased T2 signal in the occiput and spinous processes of C1 and C2 in keeping with fluid within the areas of pneumatization (white arrows). Normal visualized spinal cord.

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Display figure 7 in original size
Figure 7: Summary table for craniocervical pneumatization

Figure 7: Table (Open in original size)
Summary table for craniocervical pneumatization

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Display figure 8 in original size
Figure 8: Differential diagnosis table for craniocervical pneumatization

Figure 8: Table (Open in original size)
Differential diagnosis table for craniocervical pneumatization

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  REFERENCES
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  ABBREVIATIONS
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CT = Computed tomography
ENT = Ear, Nose and Throat









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