ABSTRACT
BACKGROUND: Petrous apicitis (PA) is a serious infection involving the apical portion of the petrous temporal bone. The classic triad of purulent otorrhea, ipsilateral abducens nerve palsy and retroorbital pain is rarely seen due to early detection and widespread use of antibiotics. Medical management is the primary treatment modality with surgery reserved for cases of recalcitrant petrous apex abscess. METHODS AND RESULTS: We presented a case of PA with previously untreated otitis media. After multidisciplinary evaluation, the patient was initially treated with intravenous antibiotics followed by drainage of the abscess using a combined transmastoid and middle cranial fossa (MCF) approach. The patient recovered well with no recurrence of the infection based on imaging and symptoms. DISCUSSION: While a variety of different surgical approaches can be used in treatment of PA, we recommend the MCF approach in cases where access to the anterior petrous apex may be challenging via transcanal or transmastoid approach.
Subject(s)
Abscess/therapy , Anti-Bacterial Agents/therapeutic use , Cerebral Ventriculitis/therapy , Drainage/methods , Mastoidectomy/methods , Mastoiditis/therapy , Meningitis/therapy , Otitis Media, Suppurative/therapy , Petrositis/therapy , Abscess/diagnostic imaging , Cerebral Ventriculitis/diagnosis , Cerebral Ventriculitis/etiology , Confusion/etiology , Cranial Fossa, Middle , Earache , Humans , Male , Mastoiditis/diagnostic imaging , Meningitis/diagnosis , Meningitis/etiology , Middle Aged , Otitis Media, Suppurative/diagnostic imaging , Petrositis/diagnostic imaging , Photophobia/etiology , Streptococcus pneumoniae , Tomography, X-Ray ComputedABSTRACT
OBJECTIVE: This study gives details of a rare case of petrous apicitis that presented as Gradenigo's syndrome and was managed surgically. METHOD: This study presents a case report and review of the literature. RESULTS: A four-year-old female was admitted for failure to thrive following recent sinusitis. Physical examination was positive for right sided facial pain, photophobia and right abducens nerve palsy. Subsequent magnetic resonance imaging revealed a 1.3 × 1.7 × 1.4 cm abscess encompassing the right Meckel's cave. A computed tomography scan showed petrous apicitis and otomastoiditis, confirming Gradenigo's syndrome. The patient was taken to the operating theatre for right intact canal wall mastoidectomy with myringotomy and tube placement. She was discharged on six weeks of ceftriaxone administered by a peripherally inserted central catheter line. At a two-week post-operative visit, she showed notable improvement in neuropathic symptoms. CONCLUSION: This study presents a rare case of petrous apicitis managed surgically without the need for a craniotomy or transcochlear procedure.
Subject(s)
Magnetic Resonance Imaging/methods , Mastoiditis/surgery , Petrositis/diagnostic imaging , Petrositis/therapy , Tomography, X-Ray Computed/methods , Anti-Bacterial Agents/therapeutic use , Child, Preschool , Combined Modality Therapy , Female , Follow-Up Studies , Hearing Loss, Conductive/diagnosis , Hearing Loss, Conductive/etiology , Humans , Infusions, Intravenous , Mastoidectomy/methods , Mastoiditis/diagnostic imaging , Mastoiditis/pathology , Myringoplasty/methods , Petrositis/complications , Petrous Bone/diagnostic imaging , Petrous Bone/pathology , Petrous Bone/surgery , Rare Diseases , Risk Assessment , Severity of Illness Index , Treatment OutcomeABSTRACT
OBJECTIVES/HYPOTHESIS: Petrous apicitis (PA) is a rare complication of otitis media. Gradenigo syndrome, with the classic triad of otitis, deep pain, and abducens paralysis, is rarer still. The objective of this study was to determine if clinical presentation and management has changed over time. STUDY DESIGN: Retrospective chart review. METHODS: Forty-four patients with PA over a 40-year period were studied. Symptoms, signs, and management outcomes were studied. Historical review, surgical anatomy and approaches, pathology, and microbiology, and an illustrative case are included as appendices. RESULTS: The classical Gradenigo triad of retro-orbital pain, otitis, and abducens palsy occurred in only six of 44 patients (13.6%). Over the 40-year observation period, those needing surgery has decreased. CONCLUSIONS: Antibiotics remain the primary treatment modality. Surgery is reserved for cases failing to respond to antibiotics. One of the 44 patients in this series died of his disease. Diagnosis and management algorithms based on these observations are suggested. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:195-201, 2018.
Subject(s)
Abducens Nerve Diseases/etiology , Abducens Nerve Diseases/therapy , Otitis Media/complications , Petrositis/etiology , Petrositis/therapy , Abducens Nerve Diseases/diagnosis , Abducens Nerve Diseases/microbiology , Adolescent , Adult , Aged , Anti-Bacterial Agents/therapeutic use , Child , Diagnostic Imaging , Drainage , Female , Humans , Male , Middle Aged , Middle Ear Ventilation , Pain Measurement , Petrositis/diagnosis , Petrositis/microbiology , Prospective Studies , Retrospective Studies , Treatment OutcomeABSTRACT
A 10-year-old girl presented with signs and symptoms suggestive of Gradenigo's syndrome, a condition characterised by otorrhoea, diplopia due to abducens nerve palsy and pain in the region of the trigeminal nerve. This case examines the presentation of this condition, and the appropriate investigations. We also highlight the importance of the involvement of multiple specialities in discussing and devising a suitable management plan.
Subject(s)
Petrositis/diagnosis , Petrositis/therapy , Aspirin/therapeutic use , Ceftriaxone/therapeutic use , Child , Dexamethasone/therapeutic use , Drug Combinations , Female , Framycetin/therapeutic use , Gramicidin/therapeutic use , Humans , Treatment OutcomeABSTRACT
Gradenigo's syndrome, the triad of suppurative otitis media, abducens nerve palsy and pain in the ophthalmic division of the trigeminal nerve, remains a rare complication of otitis media. A case in a paediatric patient is described, successfully managed conservatively. There is little evidence to support increased use of antibiotics in acute otitis media to prevent this complication.
Subject(s)
Petrositis/therapy , Anti-Bacterial Agents/therapeutic use , Child , Emergency Service, Hospital , Female , Humans , Magnetic Resonance Imaging , Petrositis/diagnosis , Petrositis/drug therapy , Petrositis/pathology , Petrous Bone/pathologyABSTRACT
OBJECTIVE: To study the clinical features and conservative treatment of petrositis. METHOD: One case of petrositis was reported and literatures were reviewed. Opacificated air cells in CT, and anomalous, discontinuous hypersignal in MRI T1 and T2 provided evidence of infection of the apex of the petrous temporal bone. RESULT: The patient recovered totally after conservative treatment with intravenous antibiotic, glucocorticoid and neurotrophic therapy, and no recurrence occurred in 1 year follow-up. CT rescan showed the clear air cells of the petrous apex 4 months later. CONCLUSION: Petrositis can be diagnosed with specific clinical features, the image of CT and MRI. Conservative treatment could be a good choice.
