Case and Research Letters
Type 3 External Occipital Protuberance (Spine Type): Ultrasonographic Diagnosis of an Uncommon Cause of Subcutaneous Scalp Pseudotumor in Adolescents
Protuberancia occipital externa tipo 3 (en espina o espolón): diagnóstico ecográfico de una causa infrecuente de pseudotumor subcutáneo del cuero cabelludo en adolescentes
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La protuberancia occipital externa tipo 3 o en espina/espolón está indicada con una flecha y la distancia entre el hueso occipital y la exostosis, medida en milímetro. También podemos observar el desplazamiento superior de las capas músculo-aponeuróticas adyacentes, constituidas por el ligamento nucal, las fibras de inserción del músculo trapecio y la aponeurosis epicraneal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Gómez Zubiaur, F. Alfageme, E. López-Negrete, G. Roustan" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Gómez Zubiaur" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Alfageme" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "López-Negrete" ] 3 => array:2 [ "nombre" => "G." 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"apellidos" => "Morales-Larios" ] 2 => array:2 [ "nombre" => "E. del Río de la" "apellidos" => "Torre" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731019300687" "doi" => "10.1016/j.ad.2018.02.042" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731019300687?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219019302756?idApp=UINPBA000044" "url" => "/15782190/0000011000000009/v2_201911260739/S1578219019302756/v2_201911260739/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Type 3 External Occipital Protuberance (Spine Type): Ultrasonographic Diagnosis of an Uncommon Cause of Subcutaneous Scalp Pseudotumor in Adolescents" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "774" "paginaFinal" => "775" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Gómez Zubiaur, F. Alfageme, E. López-Negrete, G. Roustan" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Gómez Zubiaur" "email" => array:1 [ 0 => "agomezubiaur@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Alfageme" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "López-Negrete" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Roustan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitario Puerta de Hierro, Madrid, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Protuberancia occipital externa tipo 3 (en espina o espolón): diagnóstico ecográfico de una causa infrecuente de pseudotumor subcutáneo del cuero cabelludo en adolescentes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 106519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dry skull image of occipital bone with type 3 EOP. Image kindly provided by Mr Richard Dabbs. Museum of London attribution to Bermondsey Abbey SK2722 / © Museum of London.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although the gold standard for the study of skull anomalies is X-rays on two planes, limited availability in outpatient settings and the radiation inherent to X-ray image acquisition have prompted the use of alternative non-radiation imaging techniques with pediatric patients, such as ultrasonography.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Furthermore, some subcutaneous pseudotumors, especially in the head and neck region, are not actually skin tumors but alterations of bony surface. Such is the case of external occipital protuberance (EOP), which may present painful exostosis in adolescence.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Two males aged 14 and 15 years old, respectively, were referred to the Dermatology Clinic with suspected tumors at the occipital level, which had presented slow but steady growth in recent years and were causing slight discomfort in the supine position. In both cases, a hard protuberance was felt in the referred zone. One of the cases had previously been diagnosed as pilomatricoma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">An ultrasound examination was performed using a high frequency linear probe, in which no dermal or subcutaneous cellular tissue alterations were evident. However, a spine or hook shaped bony protuberance was observed on the surface of the occipital bone, contiguous with the insertion of the cervical musculature, separated from the bone table by 3<span class="elsevierStyleHsp" style=""></span>mm in the first case (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a) and 1.8<span class="elsevierStyleHsp" style=""></span>mm in the second (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Diagnosis of type 3 or spine type EOP was made, and as the lesion was almost asymptomatic, conservative follow-up was indicated.</p><p id="par0030" class="elsevierStylePara elsevierViewall">External occipital protuberance has been widely reported in the anthropological literature, but there is a paucity of information on it in medical publications. Broca classified EOP into six anatomical subtypes which Gülekon and Turgut subsequently simplified into three subtypes<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a>: smooth form (type 1), crest type (type 2) and spine type (type 3).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Type 3 EOP is an anatomical skull variant reported in 63.4% of males and 4.2% of females, and is a sex marker in forensic and anthropological studies (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). However, EOP can become symptomatic in predisposed individuals in late adolescence due to a focal bony exostosis, possibly related to growth of the neck muscles that are inserted in it, mainly the trapezius muscle. This increases in size, causing subperiosteal stretching and tenderness in the area, especially on pressure palpation.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Apart from a sonographic report by Nevo and Brohnstein<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> on transient protuberances of the occipital bone in fetuses as a differential diagnosis of encephalocele, most studies of this anatomical variation have been based on ionizing radiation diagnostic tests such as X-rays or CTscans.</p><p id="par0045" class="elsevierStylePara elsevierViewall">As demonstrated by these clinical cases, ultrasonography enables quick, direct diagnosis of this condition and rules out other dermal or subcutaneous skin tumors, such as calcified cephalohematoma (mainly in newborns and young children) or pilomatricoma (both in children and adults) among others.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a> Consequently, dermatologists are making increasing use of this technique, avoiding unnecessary biopsies or ionizing explorations.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The incidence of symptomatic EOP is unknown, and its management is based on analgesia. However, limited surgical resection and bony smoothing can provide a long term solution in resistant cases, as reported by Marshall et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Ultrasonography is a valid diagnostic method for EOP which is easily available to dermatologists and has the potential to avoid unnecessary ionizing explorations and surgery.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gómez Zubiaur A, Alfageme F, López-Negrete E, Roustan G. Type 3 External Occipital Protuberance (Spine Type): Ultrasonographic Diagnosis of an Uncommon Cause of Subcutaneous Scalp Pseudotumor in Adolescents Eczema y urticaria en Portugal. 2019;110:774–775.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1780 "Ancho" => 2083 "Tamanyo" => 203055 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High frequency ultrasound of patients showing longitudinal scan of the occipital area. Type 3 or spine type external occipital protuberance is marked with an arrow and distance between the occipital bone and the exostosis is measured in millimeters. We can also observe the upward displacement of the adjacent musculoaponeurotic layers, constituted by the nuchal ligament, insertion fibers of the trapezius muscle and the epicranial aponeurosis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 106519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dry skull image of occipital bone with type 3 EOP. Image kindly provided by Mr Richard Dabbs. Museum of London attribution to Bermondsey Abbey SK2722 / © Museum of London.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sonography in pathologies of scalp and hair" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "X. Wortsman" 1 => "J. Wortsman" 2 => "L. Matsuoka" 3 => "T. Saavedra" 4 => "F. Mardones" 5 => "D. Saavedra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1259/bjr/22636640" "Revista" => array:6 [ "tituloSerie" => "Br J Radiol." 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 29 | 8 | 37 |
| 2024 Octubre | 334 | 57 | 391 |
| 2024 Septiembre | 298 | 34 | 332 |
| 2024 Agosto | 292 | 66 | 358 |
| 2024 Julio | 309 | 33 | 342 |
| 2024 Junio | 277 | 39 | 316 |
| 2024 Mayo | 296 | 37 | 333 |
| 2024 Abril | 250 | 45 | 295 |
| 2024 Marzo | 363 | 32 | 395 |
| 2024 Febrero | 412 | 43 | 455 |
| 2024 Enero | 525 | 41 | 566 |
| 2023 Diciembre | 325 | 41 | 366 |
| 2023 Noviembre | 327 | 44 | 371 |
| 2023 Octubre | 333 | 80 | 413 |
| 2023 Septiembre | 272 | 64 | 336 |
| 2023 Agosto | 147 | 49 | 196 |
| 2023 Julio | 178 | 70 | 248 |
| 2023 Junio | 209 | 43 | 252 |
| 2023 Mayo | 190 | 47 | 237 |
| 2023 Abril | 215 | 28 | 243 |
| 2023 Marzo | 206 | 27 | 233 |
| 2023 Febrero | 214 | 30 | 244 |
| 2023 Enero | 134 | 50 | 184 |
| 2022 Diciembre | 179 | 44 | 223 |
| 2022 Noviembre | 132 | 41 | 173 |
| 2022 Octubre | 114 | 30 | 144 |
| 2022 Septiembre | 70 | 42 | 112 |
| 2022 Agosto | 60 | 44 | 104 |
| 2022 Julio | 36 | 55 | 91 |
| 2022 Junio | 54 | 37 | 91 |
| 2022 Mayo | 180 | 52 | 232 |
| 2022 Abril | 224 | 30 | 254 |
| 2022 Marzo | 298 | 61 | 359 |
| 2022 Febrero | 205 | 26 | 231 |
| 2022 Enero | 238 | 47 | 285 |
| 2021 Diciembre | 243 | 40 | 283 |
| 2021 Noviembre | 185 | 53 | 238 |
| 2021 Octubre | 265 | 73 | 338 |
| 2021 Septiembre | 193 | 53 | 246 |
| 2021 Agosto | 212 | 30 | 242 |
| 2021 Julio | 162 | 29 | 191 |
| 2021 Junio | 123 | 39 | 162 |
| 2021 Mayo | 85 | 54 | 139 |
| 2021 Abril | 230 | 60 | 290 |
| 2021 Marzo | 150 | 40 | 190 |
| 2021 Febrero | 110 | 37 | 147 |
| 2021 Enero | 106 | 25 | 131 |
| 2020 Diciembre | 132 | 32 | 164 |
| 2020 Noviembre | 79 | 21 | 100 |
| 2020 Octubre | 69 | 22 | 91 |
| 2020 Septiembre | 47 | 18 | 65 |
| 2020 Agosto | 67 | 16 | 83 |
| 2020 Julio | 26 | 17 | 43 |
| 2020 Junio | 28 | 25 | 53 |
| 2020 Mayo | 18 | 14 | 32 |
| 2020 Abril | 14 | 10 | 24 |
| 2020 Marzo | 12 | 2 | 14 |
| 2020 Febrero | 4 | 2 | 6 |
| 2019 Diciembre | 1 | 2 | 3 |
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