Question 15.3
This is the second part of a multi-part SAQ. The first part was as follows:
You are called to review a 48-year-old male in the post-operative recovery unit (PACIJ) who has just undergone resection of a TSH-secreting pituitary adenoma via a trans-sphenoidal approach. He is febrile (38.5'C) and is hypertensive (160/50 mmHg) with tachycardia (130 beats/min) and hyper-dynamic circulation, and is hyper-reflexic.
Give the likely diagnosis. (10% marks)
List your immediate pharmacological management. (30% marks)
The patient subsequently recovered and was discharged home. He re-presented two weeks later with increasing drowsiness, confusion, fevers, neck stiffness and a clear nasal discharge.
Give the likely diagnosis. (10% marks)
Briefly outline your immediate management. (30% marks)
Three days after re-admission, the same patient was the subject of a Rapid Response System (RRS) call for decreased consciousness.
Images 1 and 2 (both shown On page 12) are slices from the CT head scan taken at the time of this event.
What complication has occurred? (20% marks)
College answer
e) Tension pneumocephaly (Mount Fuji sign) secondary to malpositioned nasopharyngeal airway tube
Discussion
This image was stolen shamelessly from a 2015 paper by Dabdoub et al. The college image had a lot more air in the various inner spaces of the skull, and there was no conspicuous burrhole in the bony windows images.
Also, there was a malpositioned nasopharyngeal airway. Can you people guess how hard it is to find a CT with pneumoencephalus and an intracranial nasopharyngeal airway? One can hardly find examples of the latter, even though it appears to be frighteningly common; and when you do they look like this one from Muzzi et al (1991)
Anyway. After having their TSH-oma resection complicated by thyroid storm and basal meningitis, the poor patient now has tension pneumoencephalus. The characteristic feature of tension in this case is the lens-like curvature of the air pocket, suggesting that it is pushing on the brain tissue.
References
Dabdoub, Carlos B., et al. "Review of the management of pneumocephalus."Surgical neurology international 6 (2015).