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Mr Papadopoulos and colleagues (November 2001 JRSM1) report an extradural haematoma (EDH) ‘caused by spread of inflammation beyond the confines of the sinus’. However, there are strong grounds for proposing dural pneumodissection. The key to their case is surely the sudden severe headache. Sinusitis does not explain exacerbation of chronic headache. Also, even if sinusitis causes EDH, it is unclear what initiates the actual bleed, especially with healthy meningeal arteries2. This is solved by postulating forceful extradural air entry via a fistula after coughing or sneezing by vigorous males. An 11-year-old boy3 repeatedly denied head trauma but was not asked about barotrauma. X-rays showed intracranial air and EDH, so dural pneumodissection with slow bleeding from small vessels was proposed. A 30-year-old man4 had an EDH which decompressed via the ear; air was found inside the EDH. A violent nose-blow can cause or reopen a cerebrospinal fluid (CSF) mastoid fistula, and air can be forced into cerebral ventricles5. CSF fistulas are very common, and CSF pooling in sinuses causes sinus overload and infection6,7. Ataya's 31-year-old asthmatic8 presented with sudden exacerbation of headache. No cause for this was given, but the patient was not asked about violent wheezing. An EDH in a 16-year-old girl9 was associated with ipsilateral maxillary, not frontal, sinusitis, so EDH is not ‘always adjacent to the infected region’1. Even when it was3, the bone fistula was in the ethmoid sinus.
The EDH reported by Papadopoulos et al. was almost circular, suggesting a strong point source of inward pressure. It may contain two residual air bubbles, common in boys with traumatic fistulas10. Traumatic EDHs are commonest near ears and nose where air can be forced in.