Limits...
Infiltrative mass of the skull base and nasopharynx: A diagnostic conundrum.

George MM, Goswamy J, Solanki K, Bhalla R - Ann Med Surg (Lond) (2015)

Bottom Line: Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration.She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine.Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures.

View Article: PubMed Central - PubMed

Affiliation: Department of Otolaryngology-Head and Neck Surgery, Manchester Royal Infirmary, Oxford Road, M13 9WL, UK.

ABSTRACT
Inflammatory skull base masses are enigmatic and often behaviourally unpredictable. We present a case of idiopathic hypertrophic pachymeningitis (IHP) forming a central skull base mass to illustrate the process required when one investigates such skull base lesions. This is the first description of mass forming or tumefactive IHP extending into the nasopharynx. A 32-year old woman presented with frontal headaches and nasal discharge. She then deteriorated and was admitted with worsening headaches, serosanguinous nasal discharge and bilateral ophthalmoplegia. Multimodality imaging confirmed a destructive central skull base soft tissue mass involving the posterior clivus, floor of sphenoid sinus, nasopharynx and extending into both cavernous sinuses. Unfortunately, the patient continued to deteriorate despite treatment with broad-spectrum antibiotics. Cerebrospinal fluid, blood tests and transnasal biopsies for histology and microbiology did not reveal a diagnosis. Further neuroimaging revealed extension of the mass. Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration. She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine. We discuss the complexity of this case paying special attention to the process followed in order to arrive at a diagnosis of idiopathic hypertrophic pachymeningitis based on both the clinical progression and the detailed analysis of serial skull base imaging. Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures.

No MeSH data available.


Related in: MedlinePlus

a) MRI head T1 weighted post contrast axial slice. After termination of corticosteroids, MRI demonstrates significant hypertrophy of skull base lesion with further compression of internal carotid arteries in cavernous sinuses (arrows). b) MRI head T1 weighted post contrast saggital slice in midline. After termination of corticosteroids, MRI demonstrates mass extending from skull base into pituitary fossa, through sphenoid sinus and into nasopharynx. Involvement of posterior clivus is clear (arrow).
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4402385&req=5

fig2: a) MRI head T1 weighted post contrast axial slice. After termination of corticosteroids, MRI demonstrates significant hypertrophy of skull base lesion with further compression of internal carotid arteries in cavernous sinuses (arrows). b) MRI head T1 weighted post contrast saggital slice in midline. After termination of corticosteroids, MRI demonstrates mass extending from skull base into pituitary fossa, through sphenoid sinus and into nasopharynx. Involvement of posterior clivus is clear (arrow).

Mentions: She was commenced on intravenous meropenem 2 g three times daily, but continued to deteriorate with worsening right-sided ophthalmoplegia and ptosis. Microbiology and Neurology teams advised both anti-fungal and antituberculous treatment regimens along with prednisolone 50 mg once daily to minimise neurological morbidity. There was gradual improvement over the following two to three weeks with marked reduction in both ophthalmoplegia and ptosis. Her daily corticosteroids were slowly reduced, however this resulted in a dramatic deterioration in her visual acuity to perception of light in the left and finger counting in the right. Bilateral ophthalmoplegia recurred. Urgent MRI brain revealed progression of the mass to involve the pituitary fossa, further into both cavernous sinuses and increased compression of the internal carotid arteries. (See Fig. 2) She was commenced on high dose intravenous methylprednisolone. Within the first 24 h of therapy the patient noted a remarkable improvement in her visual acuity and her antibiotics were ceased.


Infiltrative mass of the skull base and nasopharynx: A diagnostic conundrum.

George MM, Goswamy J, Solanki K, Bhalla R - Ann Med Surg (Lond) (2015)

a) MRI head T1 weighted post contrast axial slice. After termination of corticosteroids, MRI demonstrates significant hypertrophy of skull base lesion with further compression of internal carotid arteries in cavernous sinuses (arrows). b) MRI head T1 weighted post contrast saggital slice in midline. After termination of corticosteroids, MRI demonstrates mass extending from skull base into pituitary fossa, through sphenoid sinus and into nasopharynx. Involvement of posterior clivus is clear (arrow).
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4402385&req=5

fig2: a) MRI head T1 weighted post contrast axial slice. After termination of corticosteroids, MRI demonstrates significant hypertrophy of skull base lesion with further compression of internal carotid arteries in cavernous sinuses (arrows). b) MRI head T1 weighted post contrast saggital slice in midline. After termination of corticosteroids, MRI demonstrates mass extending from skull base into pituitary fossa, through sphenoid sinus and into nasopharynx. Involvement of posterior clivus is clear (arrow).
Mentions: She was commenced on intravenous meropenem 2 g three times daily, but continued to deteriorate with worsening right-sided ophthalmoplegia and ptosis. Microbiology and Neurology teams advised both anti-fungal and antituberculous treatment regimens along with prednisolone 50 mg once daily to minimise neurological morbidity. There was gradual improvement over the following two to three weeks with marked reduction in both ophthalmoplegia and ptosis. Her daily corticosteroids were slowly reduced, however this resulted in a dramatic deterioration in her visual acuity to perception of light in the left and finger counting in the right. Bilateral ophthalmoplegia recurred. Urgent MRI brain revealed progression of the mass to involve the pituitary fossa, further into both cavernous sinuses and increased compression of the internal carotid arteries. (See Fig. 2) She was commenced on high dose intravenous methylprednisolone. Within the first 24 h of therapy the patient noted a remarkable improvement in her visual acuity and her antibiotics were ceased.

Bottom Line: Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration.She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine.Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures.

View Article: PubMed Central - PubMed

Affiliation: Department of Otolaryngology-Head and Neck Surgery, Manchester Royal Infirmary, Oxford Road, M13 9WL, UK.

ABSTRACT
Inflammatory skull base masses are enigmatic and often behaviourally unpredictable. We present a case of idiopathic hypertrophic pachymeningitis (IHP) forming a central skull base mass to illustrate the process required when one investigates such skull base lesions. This is the first description of mass forming or tumefactive IHP extending into the nasopharynx. A 32-year old woman presented with frontal headaches and nasal discharge. She then deteriorated and was admitted with worsening headaches, serosanguinous nasal discharge and bilateral ophthalmoplegia. Multimodality imaging confirmed a destructive central skull base soft tissue mass involving the posterior clivus, floor of sphenoid sinus, nasopharynx and extending into both cavernous sinuses. Unfortunately, the patient continued to deteriorate despite treatment with broad-spectrum antibiotics. Cerebrospinal fluid, blood tests and transnasal biopsies for histology and microbiology did not reveal a diagnosis. Further neuroimaging revealed extension of the mass. Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration. She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine. We discuss the complexity of this case paying special attention to the process followed in order to arrive at a diagnosis of idiopathic hypertrophic pachymeningitis based on both the clinical progression and the detailed analysis of serial skull base imaging. Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures.

No MeSH data available.


Related in: MedlinePlus