Rapid Deterioration in a Patient With Spontaneous Otogenic Pneumocephalus

Abstract

Pneumocephalus is defined as air in the cranial cavity. It typically occurs after trauma, surgical procedures, intracranial infections, or related to a tumor. Spontaneous pneumocephalus is very rare, with less than 30 reported cases, but prompt identification and management remain important for neuro-intensivists.[1-2] CASE PRESENTATION: 79 year-old man with remote bilateral carotid endarterectomies presented with 10 days of progressing severe headache, new right-sided tinnitus and ear fullness. He denied recent head trauma, valsalva maneuver, constipation, excessive coughing or other provoking causes. His exam was without focal deficits. Otoscopic exam was normal. His bloodwork was unrevealing. Initial head Computer Tomography (CT) showed intracranial air (Figure 1A-B). He was managed with conservative measures initially, however several hours later he became abruptly altered without change in pupillary size. Repeat CT demonstrated worsening pneumocephalus (Figure 1C-D) involving the bilateral subarachnoid spaces, right temporal lobe intraparenchymal tissue, and entire ventricular system. Bony dehiscences of the right tegmen mastoideum were suspected. He underwent right middle fossa craniotomy with repair of multiple tegmen defects which gradually improved the pneumocephalus.