External Occipital Protuberance Projecting as Downward Curved Horn Presenting with Intractable Occipital Pain: Report of a First Case.

External occipital protuberance is normal anatomical entity, rarely it may show hyperostosis and may get prominent and causing pain and examination reveals presence of tender bony swelling. However, such occurrence is extremely uncommon. Copyright:

A 14-year-old boy presented with pain localized in the occipital region along with the presence of slowly growing curved bony mass for five years. He used to have difficulty in combing and sleeping in supine posture He consulted physicians but pain persisted. Local examination revealed the presence of a non-tender, stony hard swelling of approximately 1.2cm in length and curved conical in shape, located over the occipital protuberance region with a downward projection, overlying skin was freely mobile and can be pinched from the underlying mass form, unassociated with dermal sinus or discharge [Figure 1]. X-ray of skull, lateral view, showed the presence of downward pointing external occipital tubercle [Figure 2]. He is advised surgical excision in view of intractable pain and currently awaiting surgical intervention.

Figure 1

Clinical photograph showing markedly bulging external occipital protuberance with inflamed skin (arrow corrections made in the manuscript)

Figure 2

X-ray of skull (lateral view) showing downward pointing external occipital tubercle

The external occipital protuberance represents a normal anatomical prominence. However, excessive hornlike prominence is uncommon. Superior nuchal lines run laterally on both sides from external occipital protuberance and provides origin of trapezius muscle in its medial part. Our patient might be getting pain due to the impingement of trapezius muscle.[1] The third occipital nerve courses approximately 3 mm laterally in relation of external occipital protuberance, and the proposed hypothesis for persistent intractable pain includes a combination of factors.[2] However, such hornlike extra-large external protuberance causing localized occipital neuralgia is not reported in the Western literature, and to the best of our knowledge, it represents first case of its kind.

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