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Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 95-98

Unilateral left lateral rectus palsy: A rare complication of acute otitis media

Department of E. N. T, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India

Date of Submission15-Nov-2019
Date of Acceptance11-Mar-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. M B Bharathi
Department of E.N.T, JSS Academy of Higher Education And Research, Bangalore - Mysore Rd, Opposite J.S.S.Pharmacy College, Bannimantap, Mysuru, Karnataka 570015, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_126_19

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Petrous apicitis is an extension of infection from mastoid air cells into the petrous apex. The infection may also spread outside the petrous apex to affect the meninges causing meningitis, cranial nerve palsies, encephalitis, brain abscess, cavernous sinus thrombosis, and even death; however, these complications are rare. Only a few patients with petrous apicitis exhibit the complete triad described by Gradenigo comprising retro-orbital pain, sixth nerve palsy, and otorrhea. We present a rare case of petrositis with pachymeningitis with unilateral abducens nerve palsy following acute suppurative otitis media, which was successfully managed medically.

Keywords: Acute suppurative otitis media, petrous apicitis, sixth nerve palsy

How to cite this article:
Unisa T, Bharathi M B, Rakesh B S, Aggarwal N. Unilateral left lateral rectus palsy: A rare complication of acute otitis media. Indian J Otol 2020;26:95-8

How to cite this URL:
Unisa T, Bharathi M B, Rakesh B S, Aggarwal N. Unilateral left lateral rectus palsy: A rare complication of acute otitis media. Indian J Otol [serial online] 2020 [cited 2021 Jul 28];26:95-8. Available from: https://www.indianjotol.org/text.asp?2020/26/2/95/289944

  Introduction Top

Petrositis used to be a common complication of middle ear infection till the 20th century. However, with easy availability of antibiotics, the incidence of acute mastoiditis and intracranial complications of middle ear cleft infection has greatly diminished.

Petrous apicitis is a rare but fatal complication of otitis media. Around 30% of petrous bones have air cells extending into the apex, and an infection in the middle ear can extend within the temporal bone into the air cells of the petrous apex. The petrous apex may be involved with either acute or chronic temporal bone infections, and with only thin dura mater separating the trigeminal ganglion and sixth cranial nerve from the bony petrous apex, they are also vulnerable to inflammatory processes resulting in symptoms such as deep facial pain, lateral rectus muscle paralysis, and diplopia. One such triad was described by Gradenigo in 1904, which includes discharging ear, deep facial pain resulting from trigeminal involvement, and abducens nerve palsy following otitis media. The involvement of the seventh cranial nerve is thought to be a result of inflammation of the nerve as it passes through Dorello's canal under the petroclinoid ligament. Petrositis may also present with facial nerve palsy and vertigo. Even though surgical treatment has traditionally been the treatment of choice, current advances in imaging and improved and newer antibiotics have given good results with conservative management. Complications arising from acute otitis media occur most commonly in children and adolescents. Here, we describe a case of a 25-year-old male with petrous apicitis, lateral rectus palsy, and patchy meningitis secondary to acute otitis media, which was managed medically with positive outcome.

  Case Report Top

A 25-year-old male was admitted under the department of otorhinolaryngology of our hospital with a 4-day history of low-grade intermittent fever. The fever was followed by severe left ear pain of 1 day which led to profuse serous ear discharge which was bloodstained. The patient had visited a local clinic for otorrhea and taken medication for the same. The patient developed diplopia on looking toward his left within 12 h and was referred to our hospital for further management. At admission, the patient was afebrile with a pulse rate of 70/min. The left tympanic membrane was congested and retracted, and the external auditory canal showed bloodstained discharge. The right tympanic membrane was normal. Cranial nerve examination showed diplopia at the left lateral gaze with left lateral rectus palsy [Figure 1]. Facial nerve and trigeminal nerve examination was normal. Ophthalmologic examination showed a bilateral normal optic disc. Laboratory tests showed a white blood cell count of 7800/mm3 with 74% neutrophils. High-resolution computed tomography (HRCT) scan of the temporal bone showed a soft-tissue density extending into the left epitympanum, mesotympanum involving Prussak's space, and extending into mastoid air cells [Figure 2]. Opacification of the petrous apex was noted with erosion of the bony facial canal in its tympanic segment. Contrast magnetic resonance imaging (MRI) was done for further evaluation and showed altered signal intensity in the left middle ear cavity, petrous apex, and mastoid cavity appearing hyperintense on T2/fluid-attenuated inversion recovery sequences with extension into the cavernous sinus and left orbital apex. The left trigeminal nerve and abducens nerve at the entry points into Meckel's and Dorello's canal, respectively, appeared thickened and edematous with bulky left lateral pterygoid muscle. A significant pachymeningeal enhancement was seen in the suprasellar and prepontine cistern along the internal acoustic meatus and temporal bone on the left side. Seventh and eighth nerve complexes were normal [Figure 3]. After a neurology opinion, lumbar puncture was done and Cerebrospinal fluid analysis showed normal results. The diagnosis of left petrositis and pachymeningitis with unilateral abducens nerve palsy was made. Intravenous antibiotic treatment with meropenem 1 g twice daily was started. Improvement in diplopia was noted from the 3rd day. Ear discharge was sent for culture and sensitivity and yielded Staphylococcus aureus which was sensitive to most antibiotics with high susceptibility for clindamycin (minimal inhibitory concentration of 0.25 mcg/ml). Clindamycin (300 mg/twice daily) was started, but meropenem was continued because of clinical improvement. No steroids were given. Daily improvement of the symptoms was noted. After 12 days of intravenous antibiotics, eye movements became normal. Otoendoscopic examination showed reduced congestion of the tympanic membrane, and no perforation was noted. Ophthalmological examination showed normal left lateral rectus movement [Figure 4]. Repeat MRI on the 14th day showed a definite reduction in the severity of inflammation around the cavernous sinus, perineural thickening, and leptomeningeal enhancement.
Figure 1: A picture showing the patient with left lateral rectus palsy on the lateral gaze

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Figure 2: Computed tomography scan of the temporal bone showing a soft-tissue density extending into the left epitympanum, mesotympanum involving Prussak's space, and extending into mastoid air cells with opacification of the petrous apex and erosion of the bony facial canal

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Figure 3:Contrast magnetic resonance imaging showing altered signal intensity in the left middle ear cavity, petrous apex, and mastoid cavity with a significant pachymeningeal enhancement in the suprasellar and prepontine cistern along the internal acoustic meatus and temporal bone on the left side

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Figure 4: A picture of the patient posttreatment showing normal eye movements

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  Discussion Top

Petrous apicitis was associated with considerable morbidity and mortality in the preantibiotic era. The use of antibiotics has succeeded in converting what was uncommon into a rarity. In 1937, Myerson estimated that petrous apicitis occurred once in every 300 cases of otitis media,[1] but today, the incidence may be smaller than 2:100,000 patients with otitis media.[2]

Most cases of petrous apicitis are considered to occur in patients with well-developed air cell systems extending into the petrous apex, as seen in our case, and the time interval between the onset of the otitis media and the manifestation of cranial nerve dysfunction varies between 1 week and 2–3 months. In 1904, Professor G. Gradenigo described a symptom complex that included discharging ear, deep facial pain resulting from trigeminal involvement, and abducens nerve palsy following otitis media. This triad became popular as Gradenigo's syndrome; however, Panse disagreed with Gradenigo that the classic triad was the hallmark of petrous apicitis.[3] Alluding to abducens nerve palsy, Chole and Donald wrote “we must not rely on that sign to make the diagnosis of petrous apicitis.[4]” Deep facial pain was found to be a more reliable indicator of petrous apicitis. In contrast, Price and Fayad reported on a case where abducens nerve palsy was the sole feature of PA,[5] thereby highlighting the variable nature of its clinical presentation.

In addition to the triad symptoms of Gradenigo syndrome, petrous apicitis may have variable presentations. Other symptoms include ipsilateral facial paralysis due to involvement of the seventh cranial nerve, deficits of cranial nerves VIII, IX, and X, vertigo, and sensorineural hearing loss as a result of labyrinthine involvement of the inner ear. According to studies, the trigeminal nerve had the highest incidence of being involved.[6] Our patient, however, did not have any symptoms of trigeminal, facial, or audiovestibular nerve involvement, and unilateral abducens palsy was the only examination finding.

Most cases of petrous apicitis present as unilateral symptoms as in our case, and bilateral abducens nerve palsies are usually seen following meningitis, Sphenoid sinusitis, and cavernous sinus involvement as it also encases contralateral abducens nerve. Our case had unilateral abducens nerve palsy despite cavernous sinus involvement of the ipsilateral side as confirmed on MRI scan.

HRCT and MRI scans complement each other in establishing a diagnosis. HRCT also helps in deciding the optimal approach if surgery is contemplated, but one must not rely on only one of these as it can be misleading. Such was the scenario in our case where HRCT scan of the temporal bone showed a soft tissue density extending into the left epitympanum, mesotympanum involving Prussak's space, and extending into mastoid air cells giving a probable diagnosis of cholesteatoma [Figure 2] along with petrous apicitis and swaying our case toward a surgical management. But a contrast MRI done for further evaluation showed left otomastoiditis with petrous apicitis with cavernous sinus and orbital apex extension with adjacent meningitis and osteomyelitis of the skull base [Figure 3] confirming our diagnosis and further management. Jackler and Parker have summarized the MRI characteristics of common petrous apex lesions[7] with petrous apicitis showing a diminished signal on T1 and an enhanced T2-weighted signal and rim enhancement on post-gadolinium T1 scan which confirms the presence of suppuration in apicitis.

Culture done for our patient grew S. aureus, whereas a retrospective study done comparing 44 patients with petrous apicitis in both acute and chronic cases found the most common organism to be Pseudomonas aeruginosa (53.3%), S. aureus (13.3%), Propionibacteriumspp. (6.7%), Streptococcuspneumoniae (6.7%), and Prevotellaspp. (6.7%).[8]

Most authors advocate for surgery due to the possibility of fatal complications. Chole and Donald stated that aggressive surgical drainage is indicated when the diagnosis of petrous apicitis is made,[4] and Watkyn-Thomas reported that petrositis is curable by adequate mastoid operation;[9] however, recent reports advocate conservative therapy with high-dose broad-spectrum antibiotics with good intracranial penetration[2] as was followed in our case where intravenous meropenem was started. Clindamycin was also started based on culture reports. The use of steroids is controversial and was not used in our case as well. Follow-up MRI at 2–4-week intervals can be used to make certain that the condition is improving as was done in our case on the 14th day and showed a significant improvement. Treatment is carried out for 6 weeks. Prolonged therapy of between 6 weeks and 6 months has also been advocated. In our case, antibiotics were continued for 6 weeks with an improvement of symptoms and examination findings. Our case had a well-pneumatized petrous apex making the chances of recurrence high,[10] and a good level of vigilance and familiarity with various surgical approaches is vital for the successful management of the patient. Surgical management should be considered in subsequent infections as was popularly said by Lempert that “Nature may be a good doctor, but is a mighty poor surgeon.”

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Myerson MC. Suppuration of the petrous pyramid some views on its surgical management. Arch Otolaryngol 1937;26:42-8.  Back to cited text no. 1
Goldstein NA, Casselbrant ML, Bluestone CD, Kurs-Lasky M. Intratemporal complications of acute otitis media in infants and children. Otolaryngol Head Neck Surg 1998;119:444-54.  Back to cited text no. 2
Panse R. Discussion. Int Centralbl Ohrenheilk 1905;3:51.  Back to cited text no. 3
Chole RA, Donald PJ. Petrous apicitis. Clinical considerations. Ann Otol Rhinol Laryngol 1983;92:544-51.  Back to cited text no. 4
Price T, Fayad G. Abducens nerve palsy as the sole presenting symptom of petrous apicitis. J Laryngol Otol 2002;116:726-9.  Back to cited text no. 5
Motamed M, Kalan A. Gradenigo's syndrome. Postgrad Med J 2000;76:559-60.  Back to cited text no. 6
Jackler RK, Parker DA. Radiographic differential diagnosis of petrous apex lesions. Am J Otol 1992;13:561-74.  Back to cited text no. 7
Gadre AK, Chole RA. The changing face of petrous apicitis – A 40-year experience. Laryngoscope 2018;128:195-201.  Back to cited text no. 8
Watkyn-Thomas FW. The treatment of petrositis: (Section of otology). Proc R Soc Med 1936;29:267-74.  Back to cited text no. 9
Al-Ammar AY. Recurrent temporal petrositis. J Laryngol Otol 2001;115:316-8.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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