JUNE,

THE

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By

ENLARGED

BEHROOZ ARIE

AZAR-KIA, LIEBESKIND,

FORAMEN MI)., F.F.R., M.D., and BRONX,

T

HE anatomy the foramen

and ovale

described

and

Although

variations normally

ovale

may

evaluation

are

of

normal radiology have been previously

well

known6’11”7 in size of be present,”

these

changes

fifth

geal

will

the of

ciated

with

smooth

ovale.

produce ing

These

the

on

the

size

Only causing are

bone

changes,

lesion

into

in

foramen fossa

the

the

however,

depend-

and

*

From

This logical

the

Ii asoph

Division

view

foramen

ovale

of Neuroradiology,

work was supported Diseases and Stroke,

in part Public

of

tile

any

skull

the

Department

fossa

lesion.

It

although

the

en-

fonamen has

ovale

been

other

wellas

tnigeminal

slow

same

with

described

of

the

have

al-

nerve

growing

lesions

appearance

and

are

Seven cases of difchanges in the fonaand their specific are outlined.

findings REPOR’r

or a

2

I

year

side

(R).

A 3

history

logic tile

year

to

Eustachian of

exanlillatioll

presented on

tube

blockage).

diplopia i year’s

motor

with

hearing

the

right

He

ati

difficulty

duration.

Neuro-

revealed

nerve,

siXtil

CASES

old male

internlittent

swallowing

with

OF

of illlpaired

(related

developed

involve1lent

fiftil

nerve,

of tenth

and

n-

2.

Case

ovale of Radiology, Award(iF

420

Albert ii

with Einstein

NSO

1. Nasopharvngeal

with

cinoma

with

(arrows).

by a Special Fellowship Health Service.

tiiat,

it

fossa

of the lesions fonamen ovale Enlargement

aneurysms,’

SubfllentOvertiCal

the

of

CASE

reports of the literature.

fossa,”

analysis of the may facilitate

a middle

margins

roentgenologic

whether

middle

adeno-

middle

an ovale

described in this report. ferent entities causing men ovale are described

bra-

ovale and destruction of the may occur in chordomas,”#{176}’6

as,”2’

normal

stressed

may

produce

that

pathognomonic

I1(;. I.

FIG.

of

be

most

fossa.8”

reported

cyhindrom

may,

of the

scattered enlargement

of the middle

of

lesions of

primarily

posterior

diagnosis

largement

asso-

and

enlargement

a variety

extends

usually

neurofibnomatosis,

a uniform, men

are

the

foranlen

tumors,9”’9

neurinomas

hvpophvseal

‘

feel

in the

defined

nerve.4’5’9’1”5

Tnigeminal

‘

of

authors

should

ovale occurs, it is tempting to presence of a neurinoma of the

as,’

histiocytosis.2#{176}

changes

fossa

M.D., M.D.

rneningiomas

Tl’ie

facilitate

MARC,

carcinom

and

i).

foramen a careful

SCIIECHTER,

YORK

mas,”

(Fig. the

the diagnosis of lesions in the middle and the nasopharynx. When enlargement the foramen consider the

of

OVALE*

MANNIE M. JOSEPH AlAN

NEW

1973

259101

a smootil college

of margin

of Medicine,

NSRH)from

cell car-

squamous

enlargement

left

foramen

(arrow). Bronx,

the

the

New

Nationallnstitute

York. ofNeuro-

ix8,

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VOL.

No.

The

I

Enlarged

Foramen

FIG.

with

Ovale

5. Case m. an enlarged

margins

Case II. Chordoma; with a well-defined

3.

FIG.

ovale eleventh noted

widened

smooth

cranial nerves. in the nasopharynx.

Plain with

(Fig.

2).

of the

of the middle a well defined atld

A right

moderately

carotid This squamous

carotid

vascular

nasopharynx

extension ovale,

(arrow).

a well-defined

skull at

fossa

sclerotic

tissue

supplied

1ll55

by

the

and

neck

of

tile

fora-

roen

nlargin revealed in external

tile

is an example

4.rCase

into

middle

ovale

with

fossa smooth

ttlLi

brawith

out’

in

taken

projection

showed

ovale view

with there

a stiiooth outline was erosion

( Fig.

4).

the

su 1)111entovertex

enlargement

was

was adhistory spells. Plain

old female of a 9 nlonth

‘‘passing

tgenograms

This

the fossa

margin.

(K). A 25 year hospital because

II to

through of middle

skull

tile

erosion

sclerotic

ileadacise

carcinoma

of a poorly of

the

of

(Fig. of the

foranlen

In ‘I’owne’s

3).

sellae

dorsulli

a chordona,

at

confirmed

differentiated

the

CASE

nasopharynx

with

FIG.

the

of

foramen

surgery.

artery. cell

a

left

causing

CASE

was

l5S

angiogranl soft

mainly

with men

tllitted

erosion

men

tissue

Meningioma

(arrow).

foramen

margin

A soft

roentgenograms

showed

left

421

ii. Note

sellae

erosion (arrow).

of the

dorsum

FIG.

a

III history

(D).

A 48 of

year

2 years

6. Case iv. Cylindroma, with well-defined

old

fenlale

of

progressive

widened

contours

presented

foramen

(arrow).

head-

ovale

Azar-Kia,

422

Schechter,

Liebeskind

and

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‘l’his

i\Iarc

is a case

fossa

witl’i

winch

is

Ji’N1,

a meningiolila

of

extensioll

itlto

widened

and

‘]Ihis vas thought to a trigenlinal neurinoma, to be a nleningioma. CASE

to

frontal

ileadaches

for left

tile

tile

has

fiftil

a

A 3 I year for

and

sillooth

old

outline.

.,.

of

sixth

sign at

was

ad-

left-sided

of

diplopia

the left examination

cranial

of

surgery

female

because years,

il:)spital

middle ovale

foratllen

be a cllaracteristic but proved

and nunibness weeks. Physical

months

lace

.

(C)

IV

nutted

of the the

1973

for

side to

nerves

..

of tile showed he

in-

volved.

Skull 7. Case

11G.

iv.

Note orbital

elliargement

of

fissure

left

tile

tue

superior

roen tgenogranls

forallell

border

(arrow).

ovale

of the

IlleaSured nausea

aciles, all)

also

and

revealed

iflation evidence

of

dinlinished

dizziness.

corneal

as hypoalgesia

reflex

over

ophthallllic

showed

111111.

H2(),

fluid

was

a

1lltl

of

i co ng.

tile

carotid

downward

portion

ex-

Side of

as well the

left

nerve. A lumbar pressure of 230 per

cent,

and

tile

teroposterior

witi’i

of

tile

angiographv displacement internal

of

carotid

the

of left

tile

tile

).

anterior cavernous

artery.

petrous

tgenogranl

(:)f its

1llSS

Ihere

was

also

tile

enlarged

7).

‘File

sella

a large

sphenoid

of tile

soft sinus.

posterior

\vall.

IllaXillary

enlargenient tile

bowing

an_

tile

with the

of

An that

revealed on

anterior

bone.

arkedly border (Fig.

enlarged

encroaching

and

evidence

Ill

cut

. The

6)

outlined also

sho\ved

was

lateral

be grossly

to

tissue

the

tile

t of

(Fig.

clearly was

tonlographic

turcica

side

Ihere

fissure

sclerosis

lateral

fleets

fora-

(Fig.

outline disclosed of

antero-

of

roen

orl)ital

The

exani ination in the revealed sclerosis

tip

en largemen

left

was

111111.

at the

superior

xanthochroniic.

ridge with enlargement ovale which had t Smootil

Left and

fifth opening

an

protein

left

tile

distribution

tile

Roentgenographic posterior projection petrous

on

of

(liVi5iOtl

puncture

Neurologic

nuchal rigidi ty. ‘I’here was a third and sixth nerve palsy,

the

foranlen

13.9

erosion

showed

011

the

of

direct

extension

nasopharynx

foralilen of

through

the

ovale

ilere

petrous

ihe

bowing of tile posterior wall of the sinus which has been previously Lieas a pathognomonic sign of juvenile seen

tile

bone.

anterior

is

of

foramen

tile

angiofibroma,

tip

refrom

eroding

maxillary scribed

lower

ovale

a cvlindronla

ill

a case

of

cylin-

dronla.

Fic. 8. right

(arrow).

Case foramen

v. Chordoma. ovale

widening weli-(iefined

1953,

with

of the margins

11G.

9. Case

v. 1958, the right larger (arrow).

foramen

ovale

is

\oi..

118,

Ihe

No.

Enlarged

Ovale

l’oramen

423

DISCUSSION

The

foramen

the

greaten

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in

located

ovale

tufldufll,

and ; its

branch

of

meningeal artery

enters

lateral nerve

emissary

the

fifth

branch the

normal

mm.,7’8

any

men

the

the

foramen that

of

mandibular accessory

maxillary its postero-

lesser

petrosal its

posterior

ofthe size and shape is felt to be due to pass

through

section fifth

is no-

structure

Fhe

through

that

of the

cranial

increase

in

would

ovale

not

it.

size

I 1.

foranien

is of

incriminate

vertical

ovale

projection

in

mm.

varies

length

Enlargement and contour

and as

do

well

not

effacement of its caused by increased of

largements

other

the

changes indicate specific

sq.

14

the the

of the

base

of the

turcica

fifth

sarv

submentoi

width.” in

ovale

10.

Case

destroyed,

Meckel’s sphenoid (arrow).

well-defined

smooth

to

neuninoma.9

malignant,

in

slow

sella em is-

(in

or

feel

growing

lesions,

i.e., case

tile

of

from

enoccur

benign

or

forarnen

from

the

in naso-

a cvlindroma

cell

squamous

downward

true ma

the

upward

the

an

of a tn-

that

margins

penetrate

direction;

of previously

sign

\Ve

smooth

which

pharynx

was

a characteristic

with

many

either

be

nasopharvngeal

asso-

the

in

margin

ovale

thought

with

are

changes

of occipital

foramen

geminal largement

en-

skull,

enlargement

veins.”22

and

carcinoma)

middle

fossa

(in

as osteoporosis

FIG. FIG.

and

shape pathol-

hypertension, such

the

of

lesion of the right ill-defined niarginS

irregularand

enlarged c-i

in

enlargement

foramen

Meningioma

an osteolstic

fora-

cortical outlines may be intracranial pressure.”#{176}

signs

vI.

with with

Since

between

as

intracranial of

with

ciated

the mm.

2-7.4

bilateral

However,

cases

in

Case

cave \ving

mandibular

nerve

the

jIG.

A

nerve. The

In

is

and

the

largest

of the internal skull througil

cross

of

the to

nerve.

skull

veins

branch

ogv.

foramen

the

tile

and

foramen

to

The variability foramen ovale

the

the

The

this

foramina

3

corresponds

nerve.

portion, leaves

aspect. of

to

axis

tile

sphenoid,

anterolateral

trigeminal

traversing

of

i

of the

posterolateral

spinosuni

the

is

wing

v. 1964, the right middle fossa with an irregular margin (arrow).

is

1 2.

carotid right

Case artery middle

VII.

Aneurysm

(arrow) fossa.

causing

of

the

right

destruction

internal

of the

Azar-Kia,

424

Schechter,

Liebeskind

Marc margins. middle

ment

ill-defined due

to

be

readily

differentiated

of

In Case

metltS.

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and

carotid of

i’sleckel’s noted

and

of

of bone

tllt\ I’.

Case

vii.

aneurysm

Cerebral

of

angiographv

right

the

showing

internal

tile

carotid

artery

(arrow).

of chordom

noma).

Case

tension

of

ovale ‘953

iS

V

a

a and

metliflgiOtll

good

a

example

chordoma

of

was

noted.

ovale

foramen

tile

In

appeared

chordoma

middle

(Fig.

wider

and

had

fossa

with

1958

tile

the

the

ex-

obtained enlarge-

in

smooth

margins foramen

1964

in

fossa

the

(Fig.

the

floor

could

no

the

boramen

in

noid,

it

growth,

otTers and

affected. middle

Case

with

These

is

Sclerosis

of the

foramen are Soft tissue

the

iii,

first

a

part

those

well

have

produced

ments.”

\‘Ve

peanance

of

other than chordomas, pharynx. due middle

be

fossa,

same

enlarge-

foranlen

appearances

of

tile

ovale

nasofloor

are

those

the the

foramen neuninonla. and

widening

of a meningiin the naso-

fonamen

may

indicate

large

with

Well-defined

sella

smooth

foramen

entities such nien i Ilgioni 1. Il om

turcicas.

margins

ovale

have with

fifth

similar

as

of

been

nerve

changes

cilordoma,

alld

en-

neuriin other

cylindroma, ngeal carci-

ar)

ii asoph

an

character-

a.

lile

changes

genoiogic

wilich

findings

defined stiiooth meti ovale may a neurinoma Azar-Kia,

1)ivision

of

Albert

Morris

Bronx,

specific

discussed.

roent-

A

margin of an enlarged have an etiology other fifth

wellforathan

nerve.

Ml).

N’euroradiology of Radiology

Einstein

1300

suggest

are

of the

Behrooz

New

College

of

Medicine

Park Avenue York 10461 R E FE RE N C ES

1.

is wid-

of tile

bone

suggestive shadows

a large

the

and suggest Erosion of

associated

Department

apcases

such as as, and

cylindnom

erosion tile

).

could

neuninomas

Carcinomas

to extensive

forathe

of

identical ovale in

with

indicate

of a chordoma. Enlargeof pituitary adenomas are

#{176} stated

clean the

foramen

tile

of

characteristic

shown

trigeminal nieningiomas,

tile

jeflerson neurinoma

these

have the

cell \Vhen

squamous

to

neurinom as. but a tnigeminai

be

the

(Fig. are

petrous

isticallv associated nom as. We have shown

of

tile

outline findings

thought

to

findings may

are suggestive ments in cases

larged

tumor

a meningioma

smooth

with

I I ; I 2;

an enlarged tnigeminal

a

of the oma.

of the longer

to

with

lesion

(Fig.

SUMMARY

the largest of the sphe-

resistance

roentgenologic

tnigeminal “Nothing

the

least is therefore

In

foramen

ened

ovale wing

fossa, the extension into ovale, produced enlargement

men

as

boramen the greater

the

to),

be outlined. Since

lytic

fossa

extension of a nasopharyngeal tumor into tile base of the skull. Erosion of the dorsum sellae and/on calcification around the sella

foramen

9),

destroyed

and

neon-

of

into

as was seen in the study (Fig. 8), where a well-defined

ment

the

a,

a meningioma

ill-defined

growth lesion.

can enlarge-

of internal

vi,

ovale

represent

pharynx cases

an

tumor

pathology petrous

aneurysm

middle

foramen

direction

11G.

Case

1973

enlarge-

true

roentgenologic

enlarged

Iti

an

the

13). Associated

from

and cave,

iii

Therefore, fossa destruction

vii,

artery,

was

JUNE,

of 2.

Principles of the Skull. Butterworth 1962, pp. iSo. ELSBERG, C. A. Meningeal

i)UBOULAY,

U. li.

ofX-Ray Diagnosis & Co., Ltd., London, fibroblastomas

on

VOL.

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3.

1,8,

The

No.

Enlarged

undersurface of temporal lobe and their surgical treatment. Bull. Neurol. Inst., New York, 1932, 2, 95-104. FORTUNA, A., and GAMBACORTA, D. Cylindroma in region of gasserian ganglion. 7. Neurosurg.,

Foramen

MASSOUD,

14.

OLIVE,

5.

6.

7.

8.

volving

gassenian

GENOL.,

RAD.

features of neurofibromas inganglion. AM. J. ROENTTHERAPY & NUCLEAR MED.,

148I53.

1961,86,

9. JEFFERSON,

cranial

SVIEN, nerve.

H. J. Neurofibromas 7. Neurosurg., 1957,

of 14,

484505.

15.

i6.

E., and MACGEE, E. E. Radiographic diagnosis of tnigeminal neuninomas. 7. Neurosurg., 1972, 36, 1 53-I 6. POPPEN, J. L., and KING, A. B. Chordoma: cxpenience with 13 cases. 7. Neurosurg., 1952, PALACIOS,

9,

139-169.

S., and L0TRIcH, La morphologic du trou ovale et les rapports du nerf maxillaire inf#{233}rieuravec le sinus sphenoidal. Rev. laryng., 1956, 11-19. 18. SCNINZ, H. R., BAENSCH, W. B., FROMMNOLD, W., GLAUNER, R., and WELLOVER, J. Roentgen Diagnosis. Second edition. Volume 3. Skull. By L. Psenner. Grune & Stratton, 1969, pp. 141 and 163. 19. SCHISANO, G., and OLIVECRONA, H. Neuninomas of gassenian ganglion and trigeminal root. 7.

17.

RADOIEVITCH,S.,JOVANOVITCH,

N.

77,

Tnigeminal neurinomas with on malignant invasion of gasNeurosurg., 1960, 17, 306-322. senian ganglion. In: Clinical Neurosurgeny: 20. SHAPIRO, R., and ROBINSON, F. Foramen of Proceedings of the Congress of Neurologic middle fossa: phylogenetic anatomic and Surgeons. Williams & Wilkins Company, pathologic study. AM. J. ROENTGENOL., RAD. Baltimore, ‘955, pp. 11-54. THERAPY & NUCLEAR MED., 1967, 101, 77910. LAFON, R., GRos, C., LABAGNE, R., CADILNAC, 794. J., MINVIELLE, J., and VLANOVITCH, B. 21. SMITH, L. C., LANE, N., and RANKOW, R. M. Tumeur du foramen ovale, confrontations Cylindroma: report of 8 cases. Am. 7. Surg., anatomo-radiologiques. 7. tIe radiol. et d’#{233}lec1965, 110, 519-526. irol., 1953,34, 58-26O. 22. WHEELER, P. S., and HONDA, M. Enlargement ii. LINDBLOM, K. Roentgenographic study of vasof foramen ovale by increased intracranial cular channels of skull. Acta radiol., 1936, pressure. Neurology, 1965, 15, 785-786. Suppl. 30. 23. WOOD-JON ES, F. Non-metrical morphological x. LINDGREN, E. Das R#{246}ntgenbilld bei Tumoren characters of skull as criteria for racial diagdes Ganglion GasserL Acta chir. scandinav., noss. Part 1. 7. Anat., I931, 65, 179-195. 1941, 85, 181-194.

some

G.

I., and

fifth

A. Zur Rontgendiagnose des neurinoma trigemini. R#{244}ntgenpraxis, 1935, 7, 550-596. GLASAUER, F. E., and TANDON, P. N. Tngeminal neuninoma in adolescents. 7. Neurol., Neurosurg. & Psychiat., 1969,32, 562-568. HARTEL, E. Rontgenographische Dansteliung des fonamen ovaie des Sch#{228}dels. Fortschr. a. d. Geb. d. R#{246}ntgenstrahlen, 1921, 27, 493-495. HENDERSON, W. R. Note on relationship of human maxillary nerve to cavernous sinus and to emissary sinus passing through foramen ovale. 7. Anat., 1966, i, 905-908. HOLMAN, C. B., OLIVE, I., and SVIEN, H. J. Roentgenologic

156-161.

II,

4. GAAL,

425

G. E., and AWWAD, H. K. Nasopharyngeal fibnoma: its malignant potentialities and radiation therapy. Clin. Radiol., i6o,

13.

427-432.

1971,34,

Ovale

remarks

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This article has been cited by: 1. BIBLIOGRAPHY 376-393. [CrossRef]