Headache Attributed to Petrous Apicitis without Symptoms of Acute Otitis Media

Case Report

Austin J Clin Neurol 2015;2(6): 1055.

Headache Attributed to Petrous Apicitis without Symptoms of Acute Otitis Media

Young-Il Rho*

Department of Pediatrics, Chosun University School of Medicine, Korea

*Corresponding author: Young Il Rho, Department of Pediatrics, Chosun University Hospital, 365 Pilmoondaero, Dong-gu, Gwangju, 501-717, South Korea

Received: April 07, 2015; Accepted: May 10, 2015; Published: May 30, 2015

Abstract

The classical findings of petrous apicitis, also known as Gradenigo’s syndrome, include abducens nerve palsy, deep facial pain and symptoms of acute otitis media. With the widespread use of antibiotics, petrous apicitis has become an uncommon disease. However, when it occurs, it may be silent or inconspicuous at first and gradually progress to a life-threatening stage. Petrous apicitis has conventionally been treated with aggressive surgical methods. However, recent reports have described good outcomes of more conservative medical treatments with minimal surgical intervention. Here, we report a case involving a 12-year-old child with petrous apicitis without symptoms of acute otitis media, who presented with persistent headaches since 14 days. On day 2 of admission, he developed diplopia and lateral limitation of the left eye. Medical treatment resulted in favorable outcomes, and the child was in good health without headaches or abducens nerve palsy at the 2-month follow-up.

Keywords: Headache; Petrous apicitis; Otitis media

Introduction

Petrous apicitis due to otitis media has become a rare disease, particularly in children, after the widespread availability and use of antibiotics. This condition is characterized by ipsilateral abducens nerve palsy, pain in the region of the first and second divisions of the trigeminal nerve and symptoms of acute otitis media [1]. In addition, patients present with headache, diplopia, tinnitus, and trigeminal and facial nerve palsies. The clinical presentation can vary. When petrous apicitis occurs with silent or inconspicuous symptoms of otitis media, it is more dangerous and frequently fatal [2,3]. The atypical symptoms require special attention. Petrous apicitis has traditionally been treated with aggressive surgical methods. However, recent reports have described good outcomes of more conservative therapy with high-dose broad-spectrum antibiotics and/or minimal surgical intervention [4,5]. Here, we describe the clinical and neuroimaging finding of a 12-year-old boy with petrous apicitis, without symptoms of acute otitis media who presented with persistent headaches since 14 days. His condition was successfully managed with medical treatment alone.

Case Presentation

A 12-year-old boy was admitted to the pediatric neurology department with a chief complaint of daily severe headaches since 14 days. He described the headaches as follows: severe, pulsatile, 3~6 hour duration, behind the left eye, in the forehead and left temporal regions, and associated with nausea. Routine analgesics were ineffective. His medical history indicated an upper respiratory infection that occurred a month back and lasted for 3 days.

On admission, he denied any preceding infectious symptoms, including fever, sore throat, and sinus congestion, cough and ear pain. His vital signs were as follows: body temperature, 36.6°C; pulse rate, 91-beats/min; and blood pressure, 110/75 mmHg. The findings of physical examination were normal, and he was alert with no other abnormal neurological findings. Laboratory investigations revealed the following: white blood cell count 12,800/mm3, with 8,960/mm3 polymorphonuclear neutrophils; C-reactive protein, 5.43 mg/dL (reference range, <0.3); and erythrocyte sedimentation rate, 62 mm/h. His hemoglobin level, platelet count, routine chemistries, liver function profile, ammonia concentration, and electrolyte level were within reference ranges. Culture results and virus studies were normal. A diagnosis of migraine without aura was initially considered. However, the following day, he complained of double vision and developed fever. Furthermore, he was unable to fix a lateral gaze with the left eye, which suggested left abducens nerve palsy (Figure 1). Ophthalmologic examination did not reveal papilledema, and otoscopic examination finding were normal. He exhibited confusion, dysphasia, and bilateral facial palsy.