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 Table of Contents  
IMAGE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 86-87

Extracranial meningioma presenting as infratemporal fossa mass


1 Department of Radiology, St. John's Medical College, Bengaluru, Karnataka, India
2 Department of Anatomy, St. John's Medical College, Bengaluru, Karnataka, India
3 Department of Pathology, St. John's Medical College, Bengaluru, Karnataka, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Reddy Ravikanth
Department of Radiology, St. John's Medical College, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_96_17

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How to cite this article:
Ravikanth R, Mathew S, Kishan V, Selvam RP. Extracranial meningioma presenting as infratemporal fossa mass. CHRISMED J Health Res 2018;5:86-7

How to cite this URL:
Ravikanth R, Mathew S, Kishan V, Selvam RP. Extracranial meningioma presenting as infratemporal fossa mass. CHRISMED J Health Res [serial online] 2018 [cited 2019 Oct 23];5:86-7. Available from: http://www.cjhr.org/text.asp?2018/5/1/86/223135




  Description Top


A 38-year-old woman presented with left-sided headache, facial pain, and left-sided cheek swelling for 2 years. The headaches were recurrent and associated with blurring of vision and were worsened with chewing and cold exposure. The cheek swelling had an insidious and progressive onset. Associated left eye ptosis with exophthalmos was present. Microsurgical tumor excision was done using left transzygomatic and temporal approach. Histopathology of the infratemporal fossa mass lesion revealed meningioma (WHO Grade I) [Figure 1]a,[Figure 1]b,[Figure 1]c.
Figure 1: (a) Ill-defined enhancing lesion in the left infratemporal fossa, involving the medial and lateral pterygoids, masseter, and the temporalis. (b) Bony hyperostosis involving the left greater wing of sphenoid bone. (c) Biopsy from the infratemporal fossa mass revealed whorls of transitional cell pattern with abundant psammoma bodies (arrows) consistent with meningioma (WHO Grade I)

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  Discussion Top


Extradural meningioma occurs as extracranial extension of intracranial tumors. Cross-sectional imaging is an indispensable tool in the investigation of infratemporal fossa pathologies. Computed tomography (CT) and magnetic resonance imaging (MRI) exquisitely display the complex anatomy of this region. Imaging provides accurate spatial localization of pathology, differential diagnosis, and vital information for treatment planning. The common infiltrative lesions to involve the infratemporal fossa in adults are squamous cell carcinomas of the retromolar trigone and pharynx.[1] Rarely, meningiomas may extend extracranially through any of the skull base foramina (commonly jugular foramen) or by invading the skull base itself.[2] They appear as homogeneously enhancing soft-tissue masses with foci of calcification within them. Hyperostotic thickening of the involved bone is a common finding. The infratemporal fossa combines a large part of the masticator space, parapharyngeal space, and the retroantral buccal space reaching up to the skull base superiorly. The proximity of the infratemporal area to the intracranial structures, the orbit, the paranasal sinuses, the nasopharynx, and the facial area demands careful planning of surgical excision and combined procedures. Detection of possible intracranial extension and involvement of adjacent structures is mandatory before surgery.

Meningiomas are benign tumors that are derived from the arachnoid villous structures of the meninges and are common in the central nervous system. Extracranial meningioma is an unusual tumor, mainly found in the head and neck area. Hoye et al. subclassified it on the basis of the major etiologies proposed in the development of extracranial meningiomas, and the most common variety of extracranial meningiomas is that which arises from intracranial dura and extends extracranially.[3]

Two possible sources for ectopic meningiomas have been proposed.[4] First, Majoros mentioned about the embryonal arachnoid cells arise outside from the skull and spine that lined along the fusion of primitive bone and nerve sheath. Second, Shuanshoti and Panyatahana mentioned about the possible origin of the ectopic meningioma from differential maturation of pluripotent mesenchymal cells.[5] In this case, there is a question regarding the primary site of the tumor, and it might be from the soft tissue as intraoperative finding, the tumor was in temporal fossa and not arising from temporal bone and can be separated from the scalp.

Rushing et al., 2009, the largest series in analysis cases of primary extracranial meningiomas, reported that vast majority of tumors affected the scalp, and there was no particular predilection anatomically with forehead, vertex, temporal, or others.[6] It would be difficult to extrapolate association with cranial bone sutures lines, but some of the tumors were probably overlying these landmarks. Patient symptoms were referable to the anatomical site of tumor involvement. Lesion over the skin scalp and neck usually presented with a mass and usually discovered at early stage.

The histopathological diagnosis is usually straightforward; however, the diagnosis may pose challenges in these unexpected locations. The WHO classification of meningioma is benign (Grade I – 90%), atypical (Grade II – 7%), and anaplastic/malignant (Grade III – 2%). Morphologically, they are usually rounded masses with well-defined dural bases that compress and displace the underlying brain tissue without invading it. The surface of the mass is usually encapsulated with thin, fibrous tissue and may have a bosselated or polypoid appearance. Extension into the overlying bone may be present. It is easily separated from the brain tissue. Relatively low risk of recurrence or aggressive growth. Biologically, extracranial meningiomas have been observed to be benign and slow growing.[7]

CT and MRI are indispensable for the imaging of infratemporal fossa. A thorough understanding of the infratemporal fossa anatomy and evaluation of intracranial extension is essential. Bony changes such as hyperostosis provide an important clue for the diagnosis of extracranial meningiomas.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bauer GP, Volk MS, Siddiqui SY, Brecher ML, Brodsky LS, Stanievich JF, et al. Burkitt's lymphoma of the parapharyngeal space. Arch Otolaryngol Head Neck Surg 1993;119:117-20.  Back to cited text no. 1
    
2.
Kawahara N, Sasaki T, Nibu K, Sugasawa M, Ichimura K, Nakatsuka T, et al. Dumbbell type jugular foramen meningioma extending both into the posterior cranial fossa and into the parapharyngeal space: Report of 2 cases with vascular reconstruction. Acta Neurochir (Wien) 1998;140:323-30.  Back to cited text no. 2
    
3.
Hoye SJ, Hoar CS, Murray JE. Extracranial meningioma presenting asa tumor of the neck. Am J Surg 1960;100:486-9.  Back to cited text no. 3
    
4.
Rowland LP. Tumors of the meninges. In: Baltimore MD, editor. Merritt's Textbook of Neurology. 9th ed. Philadelphia: Williams & Wilkins; 1995. p. 329-35.  Back to cited text no. 4
    
5.
O'Reilly RC, Kapadia SB, Kamerer DB. Primary extracranial meningioma of the temporal bone. Otolaryngol Head Neck Surg 1998;118:690-4.  Back to cited text no. 5
    
6.
Rushing EJ, Bouffard JP, McCall S, Olsen C, Mena H, Sandberg GD, et al. Primary extracranial meningiomas: An analysis of 146 cases. Head Neck Pathol 2009;3:116-30.  Back to cited text no. 6
    
7.
Min JH, Kang SH, Lee JB, Chung YG, Lee HK. Hyperostotic meningioma with minimal tumor invasion into the skull. Neurol Med Chir (Tokyo) 2005;45:480-3.  Back to cited text no. 7
    


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