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& Volume 23, Number 5, September 2012

3. Fisher EW, Lund VJ, Rutman A. The human nasal mucosa after
deprivation of airflow: a study of laryngectomy patients. Rhinology
1992;30:5Y10
4. Fisher EW, Liu M, Lund VJ. The nasal cycle after deprivation of airflow:
a study of laryngectomy patients using acoustic rhinometry.
Acta Otolaryngol 1994;114:443Y446
5. Havas TE, Cole P, Gullane P, et al. Alterations in nasal physiology
after laryngectomy: the nasal cycle. J Otolaryngol 1987;16:
149Y153
6. Havas TE, Cole P, Gullane PJ, et al. The nasal cycle after laryngectomy.
Acta Otolaryngol 1987;103:111Y116
7. Bende M. Blood flow in human nasal mucosa after total
laryngectomy. Acta Otolaryngol 1983;96:529Y531
8. Sakakura Y, Ukai K, Majima Y, et al. Nasal mucociliary clearance
under various conditions. Acta Otolaryngol 1983;96:167Y173
9. Miani C, Ortolani F, Bracale AM, et al. Olfactory mucosa histological
findings in laryngectomies. Eur Arch Otorhinolaryngol
2003;260:529Y535
10. Rood SR, Doyle WJ. Anatomy: introduction. Ann Otol Rhinol Laryngol
1985;120:6Y8
11. Doyle WJ. Physiology: introduction. Ann Otol Rhinol Laryngol
1985;120:20Y21
12. Bento RF, Miniti A, Marone SAM. Tuba auditiva. In: Tratado de
Otologia. 1a edicao. Sao Paulo: Edusp, 1998:173Y182
13. Grimmer JF, Poe DS. Update on eustachian tube dysfunction and the
patulous eustachian tube. Curr Opin Otolaryngol Head Neck Surg
2005;13:277Y282
14. Honjo I. Clearance function of the Eustachian tube. Ann Otol Rhinol
Laryngol 1985;120:29Y30
15. Simons JP, Mehta D, Mandell DL. Assessment of constipation in
children with tracheostomy. Arch Otolaryngol Head Neck Surg
2010;136:27Y32
16. Zhen HT, Wang CF, Cui YH, et al. A new method to evaluate the
eustachian tube function. Lin Chuang Er Bi Yan Hou Ke Za Zhi
2000;14:160Y161
17. Dixon FW, Hoerr NL, McCall JW. The nasal mucosa in
laryngectomized patients. Ann Otol Rhinol Laryngol
1949;58:535Y547
18. Ewert G. On the mucous flow rate in the human nose. Acta Otolaryngol
(Stockh) 1965;200:1Y62
19. Keuning J. On the nasal cycle. Rhinology 1968;6:1Y2
20. Todisco T, Maurizi M, Paludetti G, et al. Laryngeal cancer: long-term
follow-up of respiratory functions after laryngectomy. Respiration
1984;45:303Y315
21. Deniz M, Uslu C, Ogredik EA, et al. Nasal mucociliary clearance in total
laryngectomized patients. Eur Arch Otorhinolaryngol
2006;263:1099Y1104
22. Maurizi M, Paludetti G, Almadori G, et al. Mucociliary clearance
and mucosal surface characteristics before and after total laryngectomy.
Acta Otolaryngol 1986;102:136Y145
23. Maurizi M, Tricarico L, Paludetti G, et al. La flora batterica del naso
faringe e trachea prima a dopo laringectomia. Nuovo Arch Ital Otol
1980;4:661Y671
24. Cingi C, Altin F, Cakli H, et al. Scintigraphic evaluation of nasal
mucociliary activity in unilateral chronic otitis media. J Laryngol Otol
2005;119:443Y447
25. Ghadiali SN, Banks J, Swarts JD. Finite element analysis of active
Eustachian tube function. J Appl Physiol 2004;97:648Y654
26. Holmquist J. Eustachian tube anatomy and physiology. J Am Aud Soc
1977;2:115Y120
27. Nguyen LH, Manoukian JJ, Sobol SE, et al. Similar allergic
inflammation in the middle ear and the upper airway: evidence
linking otitis media with effusion to the united airways concept.
J Allergy Clin Immunol 2004;114:1110Y1115
28. Bunne M, Falk B, Magnuson B, et al. Variability of Eustachian tube
function: comparison of ears with retraction disease and normal middle
ears. Laryngoscope 2000;110:1389Y1395
29. Bylander AKH. Influence of age, sex, and race on Eustachian tube
function. Ann Otol Rhinol Laryngol 1985;120:20Y21

Brief Clinical Studies

Diagnosis and Treatment of

Ossified Cephalhematoma
Bulent Guclu, MD,* Ulviye Yalcinkaya, MD,
Burak Kazanci, MD,* Utku Adilay, MD,*
Mehmet Ali Ekici, MD*
Abstract: Ossified cephalhematoma is a rare clinical entity. Even
though cephalhematoma is frequently encountered, ossified cephalhematoma occurs only sporadically. We report a 13-week-old boy who
was admitted to neurosurgery clinic with deformity of the skull. A plain
skull radiograph showed radiolucent areas in the right parietal region.
CT scan of the head showed thickened right parietal bone and a lowdensity lesion between bony layers. 3D CT of the skull showed bony
protrusion of the right parietal bone. A cosmetic surgical procedure
was performed for the patient, and biopsy of the bony lesion confirmed
ossified cephalhematoma. We discuss diagnosis, pathogenesis, and
treatment of ossified cephalhematoma.
Key Words: Ossified cephalhematoma, pathogenesis cephalhematoma, ossification cephalhematoma, treatment

ephalhematoma is a collection of blood beneath the periosteum

of the bones in the cranial vault. Cephalhematomas occur most
frequently in the neonatal period and rare at other times of life.
When a baby with a large head and borderline cephalopelvic disproportion is subjected to normal delivery, cephalhematoma may occur.
The natural course of cephalhematoma is gradual resorption. In the recent
Anglo-American literature, the occurrence of ossified cephalhematoma
is rare and restricted to few case reports.1Y4 We present a 13-week-old
boy who had ossified cephalhematoma and discuss the diagnosis,
possible pathogenesis, and treatment of the lesion.

CLINICAL REPORT
A 13-week-old boy presented with a solid swelling in the right
parietal region. His grandmother noticed soft swelling in the right
parietal region of the head when he was 3 days old. Swelling became
harder and deformed the head with time. The delivery was precipitous at 40 gestational weeks. Antenatal examination was done
regularly and was essentially normal. He was the third child of the
family. The first child was a boy who died from acute lymphoblastic
leukemia when he was 4.5 years old. His physical and neurological
examination was normal except swelling in the head. On examination, the childs head circumference was 43 cm and the anterior
fontanelle was wide open. He had a 3  4 cm swelling in the right
From the *Neurosurgery Clinic, Ministry of Health, Sevket Yilmaz Research
and Training Hospital, Yildirim, Bursa; and Pathology Department,
Uludag University Hospital, Bursa, Turkey.
Received April 3, 2012.
Accepted for publication June 15, 2012.
Address correspondence and reprint requests to Bulent Guclu, MD,
Neurosurgery Clinic, Ministry of Health, Sevket Yilmaz Research
and Training Hospital, Yildirim, Bursa 16310, Turkey;
E-mail: guclubulent@hotmail.com
The authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e318266893c

* 2012 Mutaz B. Habal, MD

Copyright 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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The Journal of Craniofacial Surgery

Brief Clinical Studies

parietal region, which was bony hard and fixed to the bone. The
scalp was freely moving over the swelling. Laboratory investigations
were normal. He had no clinical signs of any bleeding diathesis.
Skull X-ray showed radiolucent areas in the right parietal region
(Fig. 1). CT scan of the head showed normal brain parenchyma and
a localized right parietal bony lesion in the skull and a soft-tissue
density within. The inner bone was continuous with the general
contour of the normal skull, and the outer bone was bulging out
abnormally. 3D CT of the skull showed bony protrusion of the right
parietal bone (Fig. 2). Because of cancer history in the family, the
family was anxious about the pathology of the swelling and shape
of the head. The child underwent surgical excision of the ossified
swelling for obtaining specimen for pathologic examination and
cosmetic reasons when he was 15 weeks old. The outer bulging
pathological bone with the organizing hematoma was excised. Histopathological examination of the specimen revealed bone trabeculae, which either formed anastomosis or were placed parallelly,
containing edematous areas and bone marrow elements surrounded
by osteoblastic rim (Fig. 3).

DISCUSSION
Cephalhematoma is a collection of blood beneath the periosteum of
the cranial vault bone. It occurs secondary to rupture of blood
vessels between the skull and the periosteum mostly in the newborn
due to birth trauma and rarely at other times following trauma or
surgeries. The use of delivery-assisting instruments, including delivery forceps or vacuum suction devices, has been associated with
cephalhematoma.5Y8 The frequency of neonatal cephalhematoma is
reported to be 0.2Y2.49% of live births.9,10 The exact mechanism of
development of cephalhematoma is not clear. It is presumed that
sudden or prolonged compression of the skull causes sudden inward
movement of the skull, displacing the bone away from the periosteum, or some shearing forces occur between the periosteum and
skull bone during delivery. There are no real tables in the skull in
infancy. When the periosteum strips away from the bone, it damages
the blood vessels and hemorrhage occurs. Also, premature rupture
of membranes might cause cephalhematoma to occur in utero with a
frequency of 0.04%.11 Recognition and anticipation of obstetric risk
factors potentially avoids nearly half of cephalhematomas.12
Diagnosis of cephalhematoma is not difficult because it is an
immobile, firm, localized mass limited by pericranial attachment to
the suture line and scalp over the swelling moves freely. The most
common location of cephalhematoma is the parietal region; however,
it occasionally occurs in occipital and frontal regions. Anemia due to
cephalhematoma is rare; however, hyperbilirubinemia may occur due
to resolving hematoma. It may rarely lead to meningitis or osteomyelitis. Linear skull fractures may underlie cephalhematoma in 5Y20%
of cases, and rarely intracranial injury is seen.13 Cephalhematoma
resolves in more than 80% by gradual hemolysis, and swelling
becomes increasingly fluctuant and finally resolves by 3Y4 weeks.
Time of treatment, state of brain, associated complication, and underlying cause affect the outcome which is favorable in most cases.
Differential diagnosis of cephalhematoma in cases with no neurological deficits includes birth trauma complications like subgaleal

FIGURE 1. Skull X-ray showing radiolucent areas in the right parietal region
(arrows).

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& Volume 23, Number 5, September 2012

FIGURE 2. A, CT scan of the head showing normal brain parenchyma,

thickened right parietal bone, and localized right parietal bony lesion. B, CT
scan with windows of the head showing a localized right parietal bony lesion
in the skull bordered by bones and a soft-tissue density within. The inner bone
was continuous with the general contour of the normal skull, and the outer
bone was bulging out abnormally. C, 3D CT of the skull showing bony
protrusion of the right parietal bone.

hematoma, caput succedaneum, vacuum caput, leptomeningeal cyst,

or congenital anomalies like meningoceles. Ossified extradural or
subdural hematoma may cause neurological deficits and should be
included in differential diagnosis. Simple observation is the treatment
of choice in most cases. If blood accumulation is significant, transfusion and phototherapy may be required. Aspiration should be
avoided because it may increase the risk of infection and late-onset
anemia.14 Skull radiography or CT scanning is indicated if there are
neurological symptoms or when concomitant depressed skull fracture
is suspected.
When the hematoma does not resolve spontaneously, it may get
organized, and ossification may be seen.1,15 After ossification,
cephalhematoma may still get absorbed slowly and most often disappears over 3Y6 months. Persistent calcification which is not resolved by time may be an indication for surgical excision. In a few
published cases in the literature, the original calvarial bone forms the
inner wall and the newly ossified bone the outer wall. There may still
be the organized hematoma in the intervening space between 2 bony
walls. The newly laid outer ossified bone may even show hemopoietic tissue in the marrow spaces enclosed by the mature trabeculae of lamellar bone.16 Possibly, the osteogenic progenitor cells in
the periosteum along with the cytokines and growth factors in the
hematoma play a role in the process of ossification, akin to the events
occurring at a healing fracture site. Sometimes ossified cephalhematoma occurs combined with sagittal craniosynostosis. Cephalhematoma in sagittal synostosis is induced by periosteal detachment of
the midline by strong shearing forces because molding is hindered in
the lateral direction. Frequent and fast complete ossification is
possibly directed by the same local factors which lead to premature
fusion of cranial sutures.3 No significant reduction in size of the
ossified cephalhematoma can be anticipated. Surgical intervention
for cosmetic reasons may sometimes become necessary. Sometimes
the diagnosis of ossified cephalhematoma is not clear; the biopsy of

FIGURE 3. Histopathological examination of the specimen revealed bone

trabeculae containing edematous areas and bone marrow elements surrounded
by osteoblastic rim. Bone trabeculae either formed anastomosis or were
placed parallelly. A, Edema between bone trabeculae (hematoxylin-eosin,
original magnification 2.5). B, Osteoblastic rim (black arrows) around the
bone trabeculae and bone marrow elements (hematoxylin-eosin, original
magnification 10).

* 2012 Mutaz B. Habal, MD

Copyright 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 23, Number 5, September 2012

the lesion may be necessary to have accurate diagnosis. After

identification of the plane between 2 bones, the outer bulging
pathological bone with the organizing hematoma is excised. The
inner real calvarial bone is maintained and secured in place. There is
no need to expose the dura if the outer table can be shaved off and
the intervening hematoma excised leaving behind the inner table in
continuity. Early operation gives a satisfactory outcome and a good
head contour due to molding. Thus, it is prudent to get X-rays or CT
scanning if the hematoma has not resolved within 6 weeks after
birth. It not only confirms the diagnosis and rules out other conditions but also delineates the extent of the lesion in all 3 dimensions,
identifying the state of the organizing hematoma and thickness of
calcification. This will also give an idea of the state of the underlying
brain parenchyma, help in planning operation, and anticipate blood
loss. Early surgery is easy and a good head shape is obtained due to
the natural molding process. The outcome is mostly good, provided
blood loss is managed efficiently. However, the risk of excessive
blood loss in a small child with limited blood volume, and chances
of dural and brain parenchymal injury with faint possibility of recurrence might persuade one to try conservative methods, which by
and large do not help the patient. The lesion may continue to grow
and might cause pressure over the developing brain, causing focal
neurological deficits and even raised intracranial pressure in
neglected children with a fused fontanelle, and if it remains evident
externally it might affect the patients head shape and psychology.
Besides, the family continues to suffer due to the stress of unknown
outcome, and repeated hospital visits add to the mental, social, and
financial burden of the family. Surgery at a later age is usually much
more extensive, prolonged, and difficult, and good head shape may
not be obtained.

CONCLUSIONS
Ossified cephalhematoma is a rare clinical entity. Even though
cephalhematoma is frequently encountered, ossified cephalhematoma is seen only sporadically. We report a 13-week-old boy who
was admitted to neurosurgery clinic with deformity of the skull and
diagnosed as having ossified cephalhematoma. We discussed diagnosis, pathogenesis, and treatment of ossified cephalhematoma.

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1. Chung HY, Chung JY, Lee DG, et al. Surgical treatment of ossified
cephalhematoma. J Craniofac Surg 2004;15:774Y779
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vaginal deliveries. Curr Opin Obstet Gynecol 2046;18:129Y134
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Brief Clinical Studies

10. Tan KL. Cephalhematoma. Aust N Z J Obstet Gynaecol

1970;10:101Y106
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Pediatr Neurosurg 2007;43:492Y497

18

F-Fluorodeoxyglucose-Positive
Warthin Tumor in a Contralateral
Cervical Lymph Node
Mimicking Metastasis in Tongue
Cancer Staging With PET/CT
Toshinori Iwai, DDS,* Junichi Baba, DDS,*
Maiko Shibasaki, DDS,* Susumu Omura, DDS, PhD,
Makoto Hirota, DDS, PhD,* Kenji Mitsudo, DDS, PhD,*
Iwai Tohnai, DDS, PhD*
Abstract: We report 18F-fluorodeoxyglucose-positive Warthin tumor in a contralateral cervical lymph node mimicking metastasis in
tongue cancer staging with positron emission tomography/computed
tomography.
Key Words: FDG-positron emission tomography/computed
tomography, Warthin tumor, cervical lymph node metastasis

18

-Fluorodeoxyglucose positron emission tomography/

computed tomography (FDG-PET/CT) is a highly effective diagnostic modality for staging in patients with head and neck
cancer.1,2 It is also applied to assess treatment response as well as
detect unknown primary cancer, secondary cancer, and distant metastasis.1,2 However, cancer patients can sometimes be misdiagnosed

From the *Department of Oral and Maxillofacial Surgery, Yokohama

City University Graduate School of Medicine, 3-9 Fukuura, Kanazawaku, Yokohama, Kanagawa 236-0004; and Department of Oral and
Maxillofacial Surgery, Yokohama City University Medical Center, 4-57
Urafunecho, Minami-ku, Yokohama 232-0024, Japan.
Received December 28, 2011.
Accepted for publication June 26, 2012.
Address correspondence and reprint requests to Toshinori Iwai, DDS,
3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004,
Japan; E-mail: iwai104oams@yahoo.co.jp
The authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e318266f750

* 2012 Mutaz B. Habal, MD

Copyright 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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