Abstract
Petrous apicitis has traditionally been treated with aggressive surgical methods. However, recent reports describe good results with more conservative medical treatment and minimal surgical intervention. We report a case of petrous apicitis presenting as the Gradenigo syndrome treated by ventilation tube insertion. We recommend aggressive surgical intervention for patients who failed to respond to conservative therapy including ventilation tube insertion.
1
Introduction
Petrositis due to acute otitis media was common at the beginning of the 20th century. However, with wide availability of antibiotics, this infection is now rare. The incidence of acute petrous apicitis is reported to be approximately 2 per 100,000 children with acute otitis media . Thirty percent of petrous bones have air cells that extend into the apex . However, petrous apex pneumatization is not essential for the spread of infection . Petrous apicitis might be the result of direct extension due to bone destruction or be due to spread via venous channels . The petrous apex may be involved in either acute or chronic temporal bone infection. The infection may spread outside of the petrous apex to affect the meninges and cranial nerves, and may be the cause of encephalitis or brain abscess formation.
Temporal petrositis may present with the triad of otorrhea, pain in the distribution of the fifth cranial nerve, and abducens palsy, classically known as Gradenigo syndrome . However, the presence of all 3 findings is not essential to indicate the presence of temporal petrositis. The classic findings of petrositis are uncommon because involvement of these structures is probably due to extradural inflammation at the petrous tip, and antibiotics usually treat the infection before dural involvement. The presence of abducens palsy is not a consistent finding in patients with petrous apicitis and should not be relied on to make the diagnosis . The involvement of the sixth cranial nerve is thought to be a result of inflammation of the nerve as it passes through the Dorello canal under the petroclinoid ligament . Petrous apicitis may also present with facial nerve palsy and vertigo .
We report a case of petrositis presenting as the Gradenigo syndrome treated by ventilation tube insertion.
2
Case report
A 10-year-old boy presented to our hospital with left otalgia and torticollis, tilting to the right side. The patient had a history of recurrent acute otitis media for 1 month. The patient also had fever, vomiting, and headache. The left eardrum was hyperemic and bulging. The results of the spinal tap were normal. The brain magnetic resonance imaging (MRI) and temporal bone computed tomography (CT) demonstrated osteomyelitis in the left petrous bone, clivus, and the condyle in the occiput extending to the prevertebral, paravertebral, and retropharyngeal regions ( Fig. 1 ). Initially, the child was treated with intravenous antibiotics (vancomycin HCl 62 mg/kg per day, cefotaxime sodium 150 mg/kg per day, metronidazole 29 mg/kg per day, and meropenem 115 mg/kg per day). Limitation of the left lateral gaze and diplopia developed after 3 days of antibiotic treatment. An ENT consultation found that the left tympanic membrane was slightly bulging with some fluid in the left middle ear cavity. A left myringotomy and ventilation tube insertion were performed. The results of bacteriologic studies were negative. Eight days after the ventilation tube insertion, the torticollis and diplopia resolved; and the general symptoms subsided. The temporal bone CT showed improvement in the retropharyngeal space, paravertebral abscess, and left petrous apicitis ( Fig. 2 ).
The patient was followed for 3 months after the first intervention; the ventilation tube was well positioned at the tympanic membrane. Follow-up MRI and CT demonstrated complete resolution of the petrous apicitis ( Fig. 3 ). The patient was symptom free at the 5-year follow-up.
