Tension pneumocephalus: an extremely small defect leading to an extremely serious problem

Pneumocephalus is a pathology characterized by air influx into the intracranial region. It may occur after head trauma and rarely after endoscopic sinus surgery. As the amount of air increases, this can cause neurological disorders with a mass effect and this condition is called tension pneumocephalus.

Our case is a 65-year-old woman. Tension pneumocephalus developed 12h after endoscopic sinus surgery performed for nasal polypectomy. Since tension pneumocephalus developed very rapidly in the patient creating a herniation table, the patient was taken to theater immediately. A burr-hole was drilled into the skull and a small defect in the ethmoid roof was closed with a layered closure technique. Post-operative conservative treatment was applied (bed rest, raising the bed head, meningitis prophylaxis, loop diuretics, abstaining from maneuvers increasing the Valsalva).

In the literature, it is stated that, in the case of a small defect, spontaneous resolution may be provided with conservative treatment, but as the size of the defect increases, neurological effects will occur more quickly and be more obvious. In our case, a herniation table developed leading to neurological and vital problems in a more rapid and more obvious way than in other tension pneumocephalus cases developing after endoscopic sinus surgery. We consider that this situation is related to a very small defect size.

Tension pneumocephalus is a complication rarely seen after endoscopic sinus surgery, but if it is not treated immediately, it may give rise to serious morbidity and mortality concerns. The clinical course developing after tension pneumocephalus may be very serious when very small defects are involved.