Clin Exp Otorhinolaryngol.  2014 Mar;7(1):59-62.

Petrositis With Bilateral Abducens Nerve Palsies complicated by Acute Otitis Media

• Choi KY
• Park SK

Abstract

Petrous apicitis is a rare but fatal complication of otitis media. An infection within the middle ear can extend within the temporal bone into the air cells of the petrous apex. With only the thin dura mater separating the trigeminal ganglion and the 6th cranial nerve from the bony petrous apex, they are vulnerable to inflammatory processes, resulting in deep facial pain, lateral rectus muscle paralysis, and diplopia. In 1904, Gradenigo described a triad of symptoms related to petrous apicitis, including acute suppurative otitis media, deep facial pain resulting from trigeminal involvement, and abducens nerve palsy. It has traditionally been treated with surgery, but recent advances in imaging, with improved antibiotic treatment, allow conservative management. In this case report, we describe a clinical and neuroradiological evolution of a child with a petrous apicitis after acute otitis media, which was managed medically with a positive outcome.

Keyword

Petrous bone; Otitis media; Abducens nerve palsy

MeSH Terms

Abducens Nerve Diseases*
Abducens Nerve*
Child
Cranial Nerves
Diplopia
Dura Mater
Ear, Middle
Facial Pain
Humans
Muscles
Otitis Media*
Otitis Media, Suppurative
Otitis*
Paralysis
Petrositis*
Petrous Bone
Temporal Bone
Trigeminal Ganglion

Figure

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  Fig. 1 Photography of the eyes at initial (A), the 16th hospital day (B), and the 30th hospital day (C). The patient had left strabismus at central gaze, and inability of full lateral gaze of both eyes suggesting both abducens nerve palsy at initial (A). Improvement of left strabismus at central gaze accompanying central diplopia and much improvement of lateral gaze of both eyes were shown at the16th hospital day (B). Improvement of left strabismus at central gaze without central diplopia, and further improvement of lateral gaze of both eyes were shown at the 30th hospital day (day of discharge).

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  Fig. 2 Fundoscopic examinations at admission (A), and at six weeks after admission (B). There was severe swelling of bilateral optic discs at admission day (A), and much improvement of blurring of the optic disc margins after six weeks (B).

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  Fig. 3 Brain magnetic resonance imaging (MRI) findings at admission: T2 weighted MRI finding (A) and T1 weighted enhanced MRI finding (B). These showed high signal intensities involving left mastoid and petrous apex (arrows).

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  Fig. 4 Temporal bone computed tomography (CT) with contrast enhancement at the 9th hospital day, showing extended pneumatization of left temporal bone to petrous apex and soft tissue densities at left mastoid and petrous apex (A). At the 21th hospital day, improved aeration of left petrous apex and mastoid with some residual soft tissue densities are shown (B). Temporal bone CT at two weeks after discharge date, showing further improvement of aeration of left petrous apex and mastoid with ventilation tube in situ (C).

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