[Radiologic diagnosis of the orbit and anterior cranial fossa]

Basing on frequent diseases associated with typical changes of the orbita and the anterior cranial fossa - osteomas, fibrous dysplasia, meningiomas of the sphenoid bone, neurofibromatosis, mucoceles and pyoceles, dermoid tumours, malignant tumours and transmitted inflammatory processes - the x-ray diagnostic procedure is explained. Plain x-ray films and computed tomography are the most important methods, whereas examinations employing film tomography and angiography are now restricted to a few selected cases only.

Maxillofacial manifestations of multiple myeloma. An unusual case and review of the literature

Oral symptoms and signs of multiple myeloma are common. An unusual case with pathologic fracture of the pterygoid process and external root resorption is presented. The literature is reviewed with respect to the prevalence of maxillofacial manifestations of multiple myeloma and the presence of such manifestations as the first sign and/or symptom of disease.

[Primary intracranial yolk sac tumor developing in the frontal lobe from the inside of the sphenoidal ridge]

A case of primary intracranial yolk sac tumor, the first known case growing in the frontal lobe, is compared with similar cases of suprasellar region. The case, 18-year-old female, suffered from headache, vomiting and visual disturbance for one month prior to the hospitalization. Plain CT scan demonstrated suppressed left anterior horn and normal density area in front of it. After injection of contrast medium, the area was enhanced distinctly. The left carotid angiography displayed a hypervascular mass in the suprasellar region and tumor stain was also seen in the capillary phase. Bilateral frontal craniectomy was performed and the tumor was almost totally removed macroscopically. The tumor situated in the left frontal lobe infiltrated into the optic nerve and a part of anterior cerebral artery. Histologically the tumor was diagnosed as yolk sac tumor according to Teilum's classification. There were stellate cells arranged in loose vacuolated network which formed cystic cavities and a complicated network of honeycomb with communicating cavities and extracellular PAS-positive hyaline globules. Glomerular-like structures (Schiller-Duval body) was also seen. Immunoperoxidase study clearly demonstrated the presence of intracytoplasmic alphafetoprotein granules in the tumor tissue. In radioimmunoassay, the level of the serum alphafetoprotein measured was two folds higher than that of the normal range, postoperatively. Although irradiation (local 3000 rads, whole 3000 rads) combined with chemotherapy (ACNU, Futraful), PSK had almost no effect. The effect of other chemotherapy (Cis-platin, VBL, Bleomycin) was indicated by the diminish size of the tumor. Five months after the onset, she was discharged with almost no neurological findings other than left visual loss. Pathological findings and clinical treatments were also discussed in detail.

[A case of giant cell tumor of the sphenoid bone--special emphasis on its clinico-radiological features and radiosensitivity]

A 19-year-old man was admitted to the hospital because of blurred vision, visual field defect, diplopia and hypesthesia of the left face. Neurological examination on admission revealed impairments of the II, III, IV, VI cranial nerves bilaterally and the first branch of the V nerve on the left. X-ray films of the skull showed a marked decalcification of the sella and upper portion of the clivus. Cerebral angiography demonstrated a moderately vascularized, large tumor in the sella-clival region. The tumor was supplied mainly by the branches of the right internal carotid artery, which was occluded at the cavernous portion. CT scans showed a large, oval mass located at the mid-portion of the anterior and middle fossa. Hounsfield number of the tumor was approximately 64.0, but several high density spots, probably due to destroyed bone fragments, were seen inside. The tumor was markedly enhanced with contrast medium. Three successive craniotomies were carried out through right fronto-temporal approaches, but total removal of the tumor was not achieved. Histological examination of surgical specimens disclosed that the tumor was consisted of abundant multinucleated giant cells and fewer spindle shaped stromal cells. Postoperative radiotherapy by telecobalt was tried and a total dose of 70Gy was delivered to the residual tumor. Effect of radiotherapy was remarkable and the size of the tumor on CT was markedly reduced to the extent of 10% of the pre-radiation tumor size. The patient was discharged in a good condition and there have been no signs of recurrence for 10 months so far. On the basis of our case and cases reported in the literature so far, the authors discussed clinical and radiological features, difficulty in surgical treatment and radiosensitivity of giant cell tumor of the sphenoid bone.

Capillary hemangioma of the sphenoid bone

A capillary hemangioma in the body of the sphenoid bone produced unilateral optic atrophy in a 13-year-old boy. The typical reticulated appearance of an osseous hemangioma was clearly demonstrated only on direct magnification radiographs. At angiography, patchy filling occurred through vessels arising from the internal carotid and internal maxillary arteries bilaterally. The few other reports of sphenoid hemangiomas are reviewed.

Metastatic small cell carcinoma of the lung presenting as pituitary apoplexy and Cushing's syndrome

We describe a woman with metastatic small cell carcinoma of the lung who presented with pituitary apoplexy and hyperprolactinemia. Within seventeen months she developed florid Cushing's syndrome with anasarca, hyperpigmentation, hypertension with marked hypercortisolemia (not suppressible with 8 mg dexamethasone), elevated serum ACTH, hypokalemic metabolic alkalosis, and multiple hepatic metastases. This picture suggested the presence of ectopic ACTH syndrome. She died 26 months after the episode of pituitary apoplexy. Primary small cell carcinoma of the lung was diagnosed post-mortem. Metastases were present in the left lung, regional lymph nodes, heart, liver, bone marrow, sphenoid bone, anterior pituitary and pituitary capsule. Posterior pituitary was normal. There was no evidence of pituitary hyperplasia, of adenoma or of primary pituitary carcinoma. The results suggest the presence of a primary ACTH-producing small cell carcinoma of the lung that metastasized to the parasellar sphenoid bone and then extended to the anterior pituitary and dura to mimic a primary intrasellar cause of pituitary apoplexy and Cushing's syndrome. The case demonstrates how difficult it may be to diagnose the etiology of Cushing's syndrome and it emphasizes a unique variation in the presentation of small cell carcinoma of the lung.

Traumatic, spontaneous and postoperative CSF rhinorrhea

CSF fistulas are a major complication of head injury but also occur spontaneously or symptomatically in connection with tumours of the skull base, empty sella syndrome, ethmoidal encephalomyelocele, intracranial hypertension or postoperatively in connection with operations on skull base tumours or ENT operations. Their main risk is the possibility of meningitis. The main clinical symptom is CSF leakage from the nose, but meningitis may be the first manifestation. Isotope cisternography and metrizamide CT cisternography are the most important methods for precise localization, sometimes also for verification of a suspected fistula. Most traumatic CSF fistulas of the frontal and ethmoidal region have to be treated operatively. The method of choice is the transfrontal approach and the closure of the fistula opening using a pedicled pericranial flap or fascia lata graft. Most sphenoidal fistulas have to be treated by packing the sphenoidal sinus with muscle. The treatment methods of the rare spontaneous and symptomatic CSF fistulas are also described. The results of operative treatment are satisfactory. About 6% recurrences, which as a rule can be cured by reoperation, and a mortality rate of about 1-3% seem to be an acceptable price for prevention of an otherwise unavoidable and oftenly deadly meningitis. Future efforts are necessary to improve the operative technique in order to reduce the incidence of anosmia. Our descriptions and advice are based not only on literature reports but also on our own experiences with a combined material of 237 cases operated on for rhinorrhea.

Cushing's disease in childhood: benign intracranial hypertension after trans-sphenoidal adenomectomy. Case report

A 7-year-old girl presented with the physical and endocrinological stigmata of Cushing's disease. An adrenocorticotropic hormone (ACTH)-producing pituitary microadenoma was excised. Three weeks after trans-sphenoidal adenomectomy, the patient developed benign intracranial hypertension. Although ACTH levels had decreased to normal, the serum cortisol had fallen to subnormal levels. The child responded to exogenous steroid therapy, which was gradually tapered and discontinued after 5 months. Normal pituitary and adrenal functions persist 2 years later.

CT evaluation of paranasal sinus tumours for cranio-facial resection

Twenty-two patients with tumours of the paranasal sinuses had computerised tomography performed prior to cranio-facial resection. The findings of CT, histology and operative appearances are compared and a 78% correlation found. The radical approach offered by cranio-facial resection allows more accurate confirmation of CT findings than hitherto possible. The particular importance of CT scanning in relation to tumours of paranasal sinuses is discussed.

Basal encephalocele and morning glory syndrome

Basal encephaloceles are often associated with other midline anomalies such as hypertelorism, broad nasal root, cleft lip, and cleft palate. Optic disc anomalies such as pallor, dysplasia, optic pit, coLoboma, and megalopapilla have been reported to occur in patients with basal encephalocele We report a case of a child with a sphenoethmoidal encephalocele and morning glory syndrome of the optic nerve. The presence of such optic nerve anomalies with facial midline anomalies should alert the clinician to the possible presence of a basal encephalocele.

Sphenoethmoidal cephalocele with cleft palate: transpalatal versus transcranial repair. Report of two cases

Two cases of sphenoethmoidal encephalocele with cleft palate are reported in detail. The encephaloceles had prolapsed into the nose and nasopharynx, and protruded into the mouth. Previous examples of this entity are reviewed. Such patients have a typical facial appearance: hypertelorism, median cleft lip, and bifid nose of varied severity. Ocular findings include coloboma of the optic nerve or anophthalmia. The prolapsed cerebral tissue varies from nonfunctional glia elements to vital structures of the hypothalamus-pituitary area. Agenesis of the corpus callosum has been reported consistently. Transcranial access to the bone defect, particularly its posterior portion, is difficult because of distorted cerebral anatomy and abnormal vasculature. The fragility of the prolapsed cerebral tissue makes it difficult to preserve the cerebral tissue intact and to reposition it into the cranium. When there is a cleft palate, it is possible to repair the encephalocele extracranially through a transoral, transpalatal approach, preserving and repositioning the content of the sac. Dural closure and obliteration of the bone defects are other essential steps of the operation. Both patients reported here were successfully operated on by the transoral, transpalatal route, at the age of 3 months and 4 years, respectively. They were followed for several years and had comprehensive endocrinological work-ups. One patient exhibited some pituitary deficiency requiring substitution therapy.

Carcinoma of the maxillary sinus. A correlation of the clinical course with orbital involvement, pterygoid erosion or pterygopalatine invasion and cervical metastases

A retrospective review of 112 cases treated by one author (J.C.) over the 21 year period 1953-1973 is performed. In 62% of the cases squamous cell carcinoma was the histologic diagnosis, with adenoid cystic carcinoma accounting for a further 16%. The remaining histologic types were few in number and included fibrosarcoma, muco-epidermoid carcinoma, melanoma, chondrosarcoma, adenocarcinoma, malignant Schwannoma, lymphosarcoma, malignant mixed tumor, rhabdomyosarcoma, angiosarcoma, and osteogenic sarcoma. Three years following diagnosis more than 1/3 of the squamous cell carcinomas were alive but by 10 years the survival rate had fallen to 16%. Orbital involvement at the time of presentation or noted at surgery had a poor prognosis with a 17% five year cure rate and only 2% alive at 10 years. Erosion of the pterygoids or pterygopalatine fossa invasion as diagnosed radiologically or intra-operatively revealed all patients dead of disease within five years despite radical surgery and irradiation. Cervical nodal metastases at primary presentation was a particularly ominous finding with all patients dead of disease within three years. Metastases developing later had a better prognosis with 39% surviving five years when treated aggressively.

Chronic isolated abducens paresis from tumors at the base of the brain

A chronic sixth-nerve paresis, even if isolated, may be neither benign nor idiopathic. We describe five patients with tumors in the basisphenoid region manifested clinically by isolated, unilateral abducens paresis for five to 20 years. There were three meningiomas (one confirmed by biopsy, two presumed), a neurilemmoma, and a chondrosarcoma. Isolated abducens paresis may persist for years in both children and adults with tumors or aneurysms. All patients with chronic sixth-nerve paresis should undergo vigorous neuroradiologic investigations to rule out a petrous apex-cavernous sinus mass lesion.