Ann Otol Rhinol LaryngollOl:1992
IMAGING CASE STUDY OF THE MONTH
PENETRATING TRAUMA OF THE JUGULAR FORAMEN M. OVERHOLT, MD, MS H. RICHARD WINN, MD
ROBERT
EDWIN
W. DALLEY, MD
ERNEST A. WEYMULLER, MD SEATTLE, WASHINGTON
PATIENT
where a combined intracranial-extracranial procedure was undertaken. A craniotomy was done to ligate the carotid artery within the carotid canal in the petrous bone. A cortical mastoidectomy was then performed and the sigmoid sinus exposed low in the mastoid. The sinus was packed with fascia and muscle. The neck was opened, the jugular vein ligated, and the internal carotid artery ligated distal to the bifurcation. A cervicofacial flap was elevated to expose the piece of wood, which was extracted without difficulty (see Figure, C). No bleeding was encountered with extraction of the stick.
A 26-year-old man fell on a sharp stick while running through a wooded area and impaled his right cheek. On evaluation in the emergency trauma center the patient was awake and lucid with stable vital signs. His voice was hoarse. Examination revealed the palpable end of a stick in his right cheek just protruding through the skin. His tongue deviated to the right and the palate elevated asymmetrically. There was no mass in the parapharyngeal space and no evidence of hematoma in the neck. The trapezius and sternocleidomastoid muscles were weak on the right. Indirect and fiberoptic examination of the larynx documented a right true vocal cord palsy. Horner's syndrome of the right eye was evident. The remainder of the findings on his neurologic evaluation were normal and nonfocal.
The patient recovered uneventfully. Findings on neurologic examination were unchanged; the patient was left with a complete right-sided palsy of cranial nerves IX, X, XI, and XII and a right-sided Horner's syndrome. Gelfoam injection of the right vocal cord was performed 2 weeks after injury to control aspiration and improve his voice. Laryngeal electromyography 6 weeks after injury failed to document any evidence of reinnervation. A thyroplasty was eventually performed to medialize the right cord; it resulted in improved vocal quality and a stronger cough.
RADIOGRAPHIC FINDINGS
Computed tomography (CT) was performed to evaluate the path of the stick (see Figure, A). The emergency CT scan obtained with contrast revealed the wooden stick as a gas-density structure. This would imply that the stick was old and dried out, since a piece of live green wood would be closer to soft tissue or water density. While conventional axial CT images document the location of the stick, the use of reformatting in the parasagittal plane parallel to the long axis of the stick gives a dramatic image of the depth of the penetration.
DISCUSSION
Paralysis of the cranial nerves exiting from the skull base is most commonly the result of a primary neoplasm (neurilemmoma or glomus tumor) involving the jugular foramen. Vernet's syndrome consists of paralysis of the cranial nerves that pass through the jugular foramen (cranial nerves IX, X, and XI). 4 Penetrating trauma is a relatively rare cause of jugular foramen syndrome. This patient had deficits resulting from paralysis of cranial nerves IX, X, XI, and XII, as well as the sympathetic nerve fibers. Villaret's syndrome is the eponym for the constellation of neurologic deficits in this patient.
Computed tomographic images also indicated sigmoid sinus thrombosis':" and internal carotid artery compression. Angiography confirmed compression and/or thrombosis of the internal carotid artery and documented intact collateral circulation distal to the occlusion via the circle of Willis. In addition, it confirmed internal jugular and sigmoid sinus thrombosis. In this case (see Figure, B), the tapered appearance of the midcervical internal carotid artery suggested that an intimal flap had developed, causing occlusion.
The surgical planning prior to removal of the stick from the jugular foramen was intended to minimize the possibility of uncontrolled bleeding upon extraction. Proximal venous control was obtained by ligation of the jugular vein in the neck, and distal control by exposing the sigmoid sinus low
MANAGEMENT
The patient was taken to the operating room,
From the Skull Base Center (all authors) and the Departments of Otolaryngology-Head and Neck Surgery (Overholt, Weymuller), Radiology (Dalley), and Neurological Surgery (Dalley, Winn) , University of Washington, Seattle, Washington.
452
Downloaded from aor.sagepub.com at OAKLAND UNIV on June 10, 2015
Overholt et al, Imaging Case Study of the Month
453
Penetrating trauma of jugular foramen. A) Parasagittal reformatted computed tomographic scan with intravenous contrast demonstrates black gas-density linear structure representing dry wooden stick extending from oral cavity posteriorly and superiorly through right jugular foramen (arrow). Tip of stick projects into right cerebellopontine angle cistern. B) Lateral right common carotid angiogram shows smooth, tapered occlusion of right internal carotid artery 4 em distal to carotid bifurcation (arrow). Wooden stick within jugular foramen has compromised adjacent cervical internal carotid artery secondary to intimal dissection originating at level at which artery entered vertical portion of carotid canal. Sigmoid sinus was also partially thrombosed (not shown). C) Wooden stick removed intraoperatively.
B
in the mastoid and packing fascia deep into the jugular bulb. The only major venous tributary not accounted for was the inferior petrosal sinus, which enters the jugular bulb anteromedially. If significant bleeding occurred upon removal of the stick, it would have been controlled by packing directly through the exposure obtained from each end of the jugular bulb. A similar approach to controlling venous bleeding in a case of traumatic jugular foramen syndrome resulting from a gunshot wound has been described previously. 5 Arterial bleeding was
controlled proximally by ligation of the internal carotid artery j list distal to the bifurcation. Distal control was obtained by ligating the carotid artery within the carotid canal in the petrous bone and prevented retrograde arterial bleeding. This combined approach resulted in minimal blood loss when the stick was extracted from the patient. Ligation of the carotid artery in the petrous bone should also prevent the potential late complication of an aneurysm or arteriovenous fistula. The reformatted CT scan in the parasagittal
Downloaded from aor.sagepub.com at OAKLAND UNIV on June 10, 2015
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Overholt et al, Imaging Case Study of the Month
plane was clearly beneficial in this case, as are CT scans in general in the evaluation of facial trauma." Angiography also added critical information for preoperative planning and should be obtained in
the setting of penetrating trauma above the angle of the mandible (zone III). It should also be considered in any trauma associated with multiple ipsilaterallower cranial nerve deficits.
REFERENCES 1. Rosenbaum AE, Wang H, Kim WS, Lewis VL, Hanley DF. Computed tomography of dural sinus thrombosis. J Comput Assist Tomogr 1986;10:16-20.
38:183-9. 4. Svien HJ, Baker HL, Rivers MH. Jugular foramen and allied syndromes. Neurology 1963;13:797-809.
2. Albertyn LE, Alcock MK. Diagnosis of internal jugular vein thrombosis. Radiology 1987;162:505-8.
5. Bauer F. Foramen jugulare syndrome caused by bullet wound. J Laryngol Otol 1962;76:367 ~ 71.
3. Grosman H, St Louis EL, Gray RR. The role of CT and DSA in cranial sinovenous occlusion. Can Assoc Radiol J 1987;
6. Duckert LG, Bolender N-F. Posttraumatic radiolucent foreign bodies. Ann Otol Rhinal Laryngol 1983;92:408-9.
SURGERY OF THE AIRWAYS Massachusetts General Hospital, Harvard Medical School, will present a postgraduate course on Surgery of the Airways to be held July 20-21,1992, in Boston, Massachusetts. For information and application forms, contact the Thoracic Surgical Unit, Massachusetts General Hospital, Boston, MA 02114; telephone (617) 726-2806; fax (617) 726-7667.
CONFERENCE ON ASSISTIVE LISTENING DEVICES GENERAL ANNOUNCEMENT AND CALL FOR PAPERS A Conference on Assistive Listening Devices, Tutorials, Applications, and Research will be held June 12-14, 1992, at The University of Iowa, Iowa City, Iowa. For information on registration and acconunodation, contact the Conference Center, University of Iowa, Memorial Union, Iowa City, IA 52242; (319) 335-3231. Fax (319) 335-3407. For information on Call for Papers, contact Regina Tisor (319) 356-2471, Fax (319) 356-4547. We have applied for Continuing Education Units from ASHA and HAle.
Downloaded from aor.sagepub.com at OAKLAND UNIV on June 10, 2015
IMAGING CASE STUDY OF THE MONTH
PENETRATING TRAUMA OF THE JUGULAR FORAMEN M. OVERHOLT, MD, MS H. RICHARD WINN, MD
ROBERT
EDWIN
W. DALLEY, MD
ERNEST A. WEYMULLER, MD SEATTLE, WASHINGTON
PATIENT
where a combined intracranial-extracranial procedure was undertaken. A craniotomy was done to ligate the carotid artery within the carotid canal in the petrous bone. A cortical mastoidectomy was then performed and the sigmoid sinus exposed low in the mastoid. The sinus was packed with fascia and muscle. The neck was opened, the jugular vein ligated, and the internal carotid artery ligated distal to the bifurcation. A cervicofacial flap was elevated to expose the piece of wood, which was extracted without difficulty (see Figure, C). No bleeding was encountered with extraction of the stick.
A 26-year-old man fell on a sharp stick while running through a wooded area and impaled his right cheek. On evaluation in the emergency trauma center the patient was awake and lucid with stable vital signs. His voice was hoarse. Examination revealed the palpable end of a stick in his right cheek just protruding through the skin. His tongue deviated to the right and the palate elevated asymmetrically. There was no mass in the parapharyngeal space and no evidence of hematoma in the neck. The trapezius and sternocleidomastoid muscles were weak on the right. Indirect and fiberoptic examination of the larynx documented a right true vocal cord palsy. Horner's syndrome of the right eye was evident. The remainder of the findings on his neurologic evaluation were normal and nonfocal.
The patient recovered uneventfully. Findings on neurologic examination were unchanged; the patient was left with a complete right-sided palsy of cranial nerves IX, X, XI, and XII and a right-sided Horner's syndrome. Gelfoam injection of the right vocal cord was performed 2 weeks after injury to control aspiration and improve his voice. Laryngeal electromyography 6 weeks after injury failed to document any evidence of reinnervation. A thyroplasty was eventually performed to medialize the right cord; it resulted in improved vocal quality and a stronger cough.
RADIOGRAPHIC FINDINGS
Computed tomography (CT) was performed to evaluate the path of the stick (see Figure, A). The emergency CT scan obtained with contrast revealed the wooden stick as a gas-density structure. This would imply that the stick was old and dried out, since a piece of live green wood would be closer to soft tissue or water density. While conventional axial CT images document the location of the stick, the use of reformatting in the parasagittal plane parallel to the long axis of the stick gives a dramatic image of the depth of the penetration.
DISCUSSION
Paralysis of the cranial nerves exiting from the skull base is most commonly the result of a primary neoplasm (neurilemmoma or glomus tumor) involving the jugular foramen. Vernet's syndrome consists of paralysis of the cranial nerves that pass through the jugular foramen (cranial nerves IX, X, and XI). 4 Penetrating trauma is a relatively rare cause of jugular foramen syndrome. This patient had deficits resulting from paralysis of cranial nerves IX, X, XI, and XII, as well as the sympathetic nerve fibers. Villaret's syndrome is the eponym for the constellation of neurologic deficits in this patient.
Computed tomographic images also indicated sigmoid sinus thrombosis':" and internal carotid artery compression. Angiography confirmed compression and/or thrombosis of the internal carotid artery and documented intact collateral circulation distal to the occlusion via the circle of Willis. In addition, it confirmed internal jugular and sigmoid sinus thrombosis. In this case (see Figure, B), the tapered appearance of the midcervical internal carotid artery suggested that an intimal flap had developed, causing occlusion.
The surgical planning prior to removal of the stick from the jugular foramen was intended to minimize the possibility of uncontrolled bleeding upon extraction. Proximal venous control was obtained by ligation of the jugular vein in the neck, and distal control by exposing the sigmoid sinus low
MANAGEMENT
The patient was taken to the operating room,
From the Skull Base Center (all authors) and the Departments of Otolaryngology-Head and Neck Surgery (Overholt, Weymuller), Radiology (Dalley), and Neurological Surgery (Dalley, Winn) , University of Washington, Seattle, Washington.
452
Downloaded from aor.sagepub.com at OAKLAND UNIV on June 10, 2015
Overholt et al, Imaging Case Study of the Month
453
Penetrating trauma of jugular foramen. A) Parasagittal reformatted computed tomographic scan with intravenous contrast demonstrates black gas-density linear structure representing dry wooden stick extending from oral cavity posteriorly and superiorly through right jugular foramen (arrow). Tip of stick projects into right cerebellopontine angle cistern. B) Lateral right common carotid angiogram shows smooth, tapered occlusion of right internal carotid artery 4 em distal to carotid bifurcation (arrow). Wooden stick within jugular foramen has compromised adjacent cervical internal carotid artery secondary to intimal dissection originating at level at which artery entered vertical portion of carotid canal. Sigmoid sinus was also partially thrombosed (not shown). C) Wooden stick removed intraoperatively.
B
in the mastoid and packing fascia deep into the jugular bulb. The only major venous tributary not accounted for was the inferior petrosal sinus, which enters the jugular bulb anteromedially. If significant bleeding occurred upon removal of the stick, it would have been controlled by packing directly through the exposure obtained from each end of the jugular bulb. A similar approach to controlling venous bleeding in a case of traumatic jugular foramen syndrome resulting from a gunshot wound has been described previously. 5 Arterial bleeding was
controlled proximally by ligation of the internal carotid artery j list distal to the bifurcation. Distal control was obtained by ligating the carotid artery within the carotid canal in the petrous bone and prevented retrograde arterial bleeding. This combined approach resulted in minimal blood loss when the stick was extracted from the patient. Ligation of the carotid artery in the petrous bone should also prevent the potential late complication of an aneurysm or arteriovenous fistula. The reformatted CT scan in the parasagittal
Downloaded from aor.sagepub.com at OAKLAND UNIV on June 10, 2015
454
Overholt et al, Imaging Case Study of the Month
plane was clearly beneficial in this case, as are CT scans in general in the evaluation of facial trauma." Angiography also added critical information for preoperative planning and should be obtained in
the setting of penetrating trauma above the angle of the mandible (zone III). It should also be considered in any trauma associated with multiple ipsilaterallower cranial nerve deficits.
REFERENCES 1. Rosenbaum AE, Wang H, Kim WS, Lewis VL, Hanley DF. Computed tomography of dural sinus thrombosis. J Comput Assist Tomogr 1986;10:16-20.
38:183-9. 4. Svien HJ, Baker HL, Rivers MH. Jugular foramen and allied syndromes. Neurology 1963;13:797-809.
2. Albertyn LE, Alcock MK. Diagnosis of internal jugular vein thrombosis. Radiology 1987;162:505-8.
5. Bauer F. Foramen jugulare syndrome caused by bullet wound. J Laryngol Otol 1962;76:367 ~ 71.
3. Grosman H, St Louis EL, Gray RR. The role of CT and DSA in cranial sinovenous occlusion. Can Assoc Radiol J 1987;
6. Duckert LG, Bolender N-F. Posttraumatic radiolucent foreign bodies. Ann Otol Rhinal Laryngol 1983;92:408-9.
SURGERY OF THE AIRWAYS Massachusetts General Hospital, Harvard Medical School, will present a postgraduate course on Surgery of the Airways to be held July 20-21,1992, in Boston, Massachusetts. For information and application forms, contact the Thoracic Surgical Unit, Massachusetts General Hospital, Boston, MA 02114; telephone (617) 726-2806; fax (617) 726-7667.
CONFERENCE ON ASSISTIVE LISTENING DEVICES GENERAL ANNOUNCEMENT AND CALL FOR PAPERS A Conference on Assistive Listening Devices, Tutorials, Applications, and Research will be held June 12-14, 1992, at The University of Iowa, Iowa City, Iowa. For information on registration and acconunodation, contact the Conference Center, University of Iowa, Memorial Union, Iowa City, IA 52242; (319) 335-3231. Fax (319) 335-3407. For information on Call for Papers, contact Regina Tisor (319) 356-2471, Fax (319) 356-4547. We have applied for Continuing Education Units from ASHA and HAle.
Downloaded from aor.sagepub.com at OAKLAND UNIV on June 10, 2015
