Intratemporal complications of acute otitis media in infants and children

Gradenigo's Syndrome With Septic Lateral Sinus Thrombosis

Gradenigo's syndrome (GS) is a rare but life-threatening complication of acute otitis media (AOM). It is classically defined as a clinical triad of acute otitis media, ipsilateral sixth (abducens) nerve palsy, and pain in the distribution of the first and second branches of the trigeminal nerve. Another rare but serious complication of AOM is venous sinus thrombosis, which is often associated with GS. The diagnosis of these conditions requires clinical suspicion, sound interpretation of signs and symptoms, and the use of the correct imaging techniques. Here, we present the case of an 81-year-old man with a previous history of recurrent otitis media, who presented with GS and septic lateral sinus thrombosis. The clinical presentation, physiopathology, and management of these conditions are discussed.

Petrous Apicitis: A Systematic Review and Case Presentation

INTRODUCTION

Petrous apicitis (PA) is a rare but dangerous complication of acute otitis media. The objective of this study is to present a case of PA and systematically review the existing literature on PA to characterize clinical presentation, diagnosis, management, and outcomes in the antibiotic era.

METHODS

A comprehensive search from 1983 to June 1, 2020, of PubMed, MEDLINE, Cochrane Library, and EmBase databases was conducted. Studies with clinical data regarding patients with PA were included. Non-English literature or studies with insufficient individual patient data were excluded. Sixty-seven studies were included with a total of 134 patients.

RESULTS

A total of 67 articles were found to meet criteria for inclusion. The mean age of presentation was 33 years. Recent acute otitis media was reported in 78 patients (58.2%). Only 3 patients (2.2%) were immunocompromised, and 8 patients (6.0%) had a history of diabetes. Gradenigo's triad of abducens palsy, otorrhea, and retro-orbital or facial pain was reported in 28 patients (20.9%); however, these presenting symptoms were common individually (51.5%, 48.5%, and 64.2%, respectively). Hearing loss (35.8%), facial weakness (17.9%), and vertigo (7.5%) were also reported.The most frequently cultured pathogen was Pseudomonas (34.2%), followed by Streptococcus and Staphylococcus. All 134 patients underwent imaging, with computed tomography being the most frequently used modality (56.0%). Nearly all patients received antibiotic therapy (95.6%), with 91 (67.9%) undergoing surgery ranging from myringotomy (26.9%) to petrosectomy (25.4%). Five patients (5.7%) died because of complications related to PA. Mean follow-up was 11.0 months.

CONCLUSIONS

Petrous apicitis has a variable presentation with potential for severe morbidity. Mortality rates are low, and presentation with Gradenigo's triad is uncommon. Appropriate medical management with surgical drainage can avoid long-term sequelae.

Cervical osteomyelitis and soft tissue polymicrobial abscess in an immunocompetent 16-year-old patient

A 16-year-old man was hospitalised with a painful space-occupying lesion in his posterior neck involving muscles, soft tissues, C1 cervical vertebra and vital cervical blood vessels. The true-cut biopsy showed inflammatory tissue. The microbiological analysis, which combined classical bacteriological and molecular methods, yielded at least four different anaerobic species. The patient was treated successfully with a prolonged course of ceftriaxone and metronidazole.

Petrous apex lesion following meningitis: management and discussion

A 9-year-old male with history of mixed hearing loss presented with petrous apex lesion following episode of meningitis. Serial imaging revealed persistence of the lesion necessitating biopsy to rule out malignancy. Biopsy revealed inflammatory changes. The management of petrous apex lesions following meningitis can be conservative but repeat imaging is necessary to rule out progression and to rule out neoplastic process.

Management of infective complications of otitis media in resource-constrained settings

PURPOSE OF REVIEW

Complications of otitis media are a cause of significant morbidity and mortality, compounded in resource-constrained settings in which human and physical resources to manage disease are suboptimal. Here, we examine the current best evidence to devise a protocol for management, in particular exploring the opportunity for conservative or nonspecialist management.

RECENT FINDINGS

Reviews of the literature suggest that intratemporal and extracranial infections can be managed with antibiotics in the first instance, with aspiration or incision and drainage of abscess. Failure to respond necessitates mastoidectomy, which need not be extensive, and can be performed with hammer and gouge. Suspected or possible intracranial extension requires referral for computed tomography (CT) imaging. Intracranial infection can in some instances be managed with antibiotics, but large or persistent intracranial abscess, or the presence of cholesteatoma requires management in a centre for specialist surgery.

SUMMARY

Many complications of otitis media could be managed by nonspecialists in appropriately equipped local or regional health facilities, and supported by appropriate training. However, regional centres with CT imaging and specialist surgery are required for assessment and treatment of cases that are suspected of having complex or advanced disease, or that fail to respond to initial treatment. Those involved in planning healthcare provision should look to develop infrastructure to support such management.

Delayed diagnosed Gradenigo's syndrome associated with acute otitis media

Gradenigo’s syndrome presents as a triad of retroorbital pain, ipsilateral abducens palsy, and purulent otorrhea. If the otologic pathologies in Gradenigo’s syndrome go unnoticed, the condition could be misdiagnosed with neurological diseases because of retroorbital pain and abducens palsy. Treatment of Gradenigo’s syndrome remains controversial. Although some reports state that long-term antibiotic treatment is sufficient, we recommended that management ought to be guided on a case-by-case basis depending on patient and disease factors. Herein, we report a delayed diagnosed pediatric case of Gradenigo’s syndrome associated with acute otitis media that was treated with ventilation tube insertion.

Petrous apex pneumatisation in children: a radiological study

OBJECTIVE

This study aimed to investigate petrous apex pneumatisation in children, as an understanding of petrous apex pneumatisation is useful in the diagnosis and surgical management of middle-ear disease.

METHODS

Computed tomography head scans from 1700 patients aged 0-16 years were assessed. Petrous apex bone and air cell volumes were calculated to determine the degree of petrous apex pneumatisation. Scans were analysed for communicating tracts between the middle ear and petrous apex.

RESULTS

Petrous apex pneumatisation was found in 21.0 per cent of patients. Positive relationships were found between age and petrous apex pneumatisation prevalence (rs = 0.990, p < 0.001), and between age and degree of petrous apex pneumatisation (rs = 0.319, p < 0.001). Petrous apex pneumatisation prevalence did not significantly differ by sex or ethnicity. Communicating tracts were identified in 84.3 per cent of patients with petrous apex pneumatisation, most commonly anterior to the otic capsule.

CONCLUSION

In children, the prevalence and degree of petrous apex pneumatisation increases with age, but prevalence is not affected by sex or ethnicity.

How well do we know Gradenigo? A comprehensive literature review and proposal for novel diagnostic categories of Gradenigo's syndrome

Gradenigo's Syndrome is a rare complication of otitis media and/or mastoiditis resulting in inflammation of the petrous apex of the temporal bone. Here, we highlight an interesting case from our institution, summarize available pediatric cases from the past fifty years to provide an updated diagnostic categorization for this rare condition with confusing nomenclature, and suggest guidance for diagnosis and management.

Gradenigo's Syndrome with Carotid Septic Stenosis

Gradenigo's syndrome was firstly described in 1907 by Giusseppe Gradenigo and is defined as the clinical triad of suppurative otitis media, ipsilateral abducens nerve palsy, and pain in the distribution of the first and the second branches of the trigeminal nerve. Since the advent of antibiotics, the incidence of this potentially life-threatening complication has diminished, but occasional cases still occur. We herein report a pediatric case of otitis media associated with Gradenigo's syndrome complicated by ipsilateral septic cavernous sinus thrombosis and infectious arteritis of the internal carotid artery.

Clinical outcomes of intracranial complications secondary to acute mastoiditis: The Alder Hey experience

OBJECTIVE

Acute mastoiditis is the most common intra-temporal complication of acute otitis media. Its management remains a challenge due to potential extracranial and intracranial complications. This study was designed to evaluate the recent experience with acute mastoiditis and its associated intracranial complications at a tertiary paediatric centre.

METHODS

A retrospective case note review was carried out for patients admitted to Alder Hey Children's Hospital between January 2006 and December 2016 with a diagnosis of acute mastoiditis. Patients were identified using ICD-10 codes H700, H701, H702, H708 and H709. A case note review was performed to identify patients with intracranial complications and data collected.

RESULTS

30 patients were identified with intracranial complications of acute mastoiditis, with 18 males and 12 females. The average age was 4 years and 2 months (range 2 months-15 years). The most common presenting complaint was otalgia and vomiting (63%), with only 27% patients presenting with mastoid swelling. 83% of patients were investigated with a combination of CT and MRI scans, 6.7% with CT scans only and 6.7% with MRI scans only. 73% were diagnosed with sinus thrombosis, 40% cerebral abscess and 33% postauricular subperiosteal abscess. 78% of the patients required surgical intervention. 27 of the 30 patients recovered fully with no significant long term sequalae following an average of 50 months follow-up.

CONCLUSION

Intracranial complications of acute mastoiditis remain a significant challenge. Most patients tend to present without mastoid swelling, necessitating a high index of suspicion in patients with picket fence fever, vomiting, drowsiness, headaches, seizures or cranial nerve involvement. Most cases treated at our institution required acute surgical intervention in addition to adjuvant medical treatment with majority patients recovering fully.

Gradenigo's syndrome with abscess of the petrous apex in pediatric patients: what is the best treatment?

BACKGROUND

Gradenigo's syndrome is defined by the classic clinical triad of ear discharge, trigeminal pain, and abducens nerve palsy. It has become a very rare nosological entity after the introduction of antibiotics, so that has been defined as the "forgotten syndrome." However, the underlying pathological process (apical petrositis) still represents a life-threatening condition that shall be immediately recognized in order to address the patient to the proper therapy. The therapy itself may be an argument of discussion: on a historical background ruled by surgery, reports of successful conservative antibiotic treatment have risen in recent years.

METHODS AND RESULTS

We reported a case of Gradenigo's syndrome in a child with an abscess of the left petrous apex and initial involvement of the carotid artery. After multidisciplinary evaluation, we decided to encourage conservative treatment, until complete regression was observed.

DISCUSSION

The available literature of the last 10 years was reviewed, with particular attention to the presence of an apical abscess and the therapeutic approach. The principles of management with regard to conservative therapy versus surgical indications are therefore examined and discussed.

Headache in Petrous Apicitis: A Case Report of Chronic Migraine-like Headache Due to Peripheral Pathology

OBJECTIVE

To report a case of petrous apicitis that manifested as chronic migraine without aura and to discuss the pathophysiological mechanisms behind this presentation.

BACKGROUND

Petrous apicitis is a rare complication of acute otitis media with varied clinical presentations that stem from the close proximity of the petrous apex to numerous neurovascular structures. Headache is among the common symptoms of petrous apicitis.

METHODS

A case of new onset headache in the setting of petrous apicitis with symptomatic response to antibiotic therapy was reported. We provided a brief review of peripheral pathophysiological mechanisms of migraine and correlated to mechanism of headache in petrous apicitis.

RESULTS

A 65-year-old man with chronic otitis externa/media presented with ongoing headache fulfilling International Classification of Headache Disorders 3rd edition (ICHD-3) criteria for chronic migraine without aura that persisted despite undergoing right mastoidectomy and tympanoplasty with multiple courses of oral antibiotic therapy for his chronic otitis. MRI brain revealed petrous apicitis, otomastoiditis, and clival osteomyelitis. His imaging findings improved and his migraine-like headache completely resolved after treatment with a prolonged course of antibiotics.

CONCLUSIONS

Petrous apicitis can present as a headache with features of migraine, and in this case in particular, as chronic migraine without aura. The pathophysiological mechanisms that may underlie the generation of migraine-like headache in petrous apicitis may include the activation of nociceptive fibers within the periosteum of the petrous apex and clivus whose cell bodies originate in the trigeminal ganglion and upper cervical dorsal root ganglia. By treating the peripheral pathology, resolution of the headache may be achieved.

Gradenigo's syndrome in a four-year-old patient: a rare diagnosis in the modern antibiotic era

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.

Neurological Complications of Acute and Chronic Otitis Media

PURPOSE OF REVIEW

The aim of this study is to discuss the symptoms, diagnosis, and management of the neurologic complications of acute and chronic otitis media.

RECENT FINDINGS

Antibiotic therapy has greatly reduced the frequency of complications of otitis media. However, it is of vital importance to remain aware of the possible development of neurologic complications. There is a trend toward less severe presenting symptoms including otorrhea, headache, nausea, and fever, with altered mental status and focal neurologic deficits presenting later. In order to reduce morbidity, early deployment of a multidisciplinary approach with prompt imaging and laboratory studies is imperative to guide appropriate management. Complications of acute and chronic otitis media may present with neurologic signs and symptoms. It is important to recognize the possible otitic origin of such complications to ensure proper management and to decrease overall morbidity and mortality.

Acute Otitis Media and Acute Coalescent Mastoiditis

Acute otitis media is a frequent manifestation of otitis media, mainly during the early childhood. The multifactorial pathogenesis and risk factors are exposed along with its most microbiological agents. The clinical manifestations and their differential diagnoses are presented. General concepts and different actual guidelines of the treatment are described, also the efficient preventive measures are proposed.

The second main issue of this chapter is to deal with the complications of acute otitis media, especially the acute coalescent mastoiditis, that is the most common suppurative complication of AOM. The pathogenesis of coalescent acute mastoiditis, its epidemiology, risk factors and the microbiological agents are presented. The clinical features and differential diagnosis are described, as the specific imaging findings. Complications of acute coalescent mastoiditis are typically the subperiosteal abscess, due to the cortical bony necrosis of the mastoid and its septa, or the intracranial spread of the infection (meningitis, intracranial abscesses and venous sinus thrombosis).

The general concept of management is exposed, with emphasis on the antimicrobial treatment and the different surgical options.

The changing face of petrous apicitis-a 40-year experience

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.

Management of acute complicated mastoiditis at an urban, tertiary care pediatric hospital

OBJECTIVES/HYPOTHESIS

To describe the presentation and management of acute complicated mastoiditis in children.

STUDY DESIGN

Retrospective case series.

METHODS

An analysis of pediatric patients with acute complicated mastoiditis treated at an urban, tertiary care children's hospital from 2007 to 2014 was performed.

RESULTS

Forty-eight patients presented with a total of 67 complications of acute mastoiditis. Mean age at presentation was 4.8 years (range = 0.1-15.3 years). The most common complications were subperiosteal abscess (n = 22, 45.8%), epidural abscess (n = 16, 33.3%), and sigmoid sinus thrombosis (n = 14, 29.2%). The most common pathogens isolated included Streptococcus pneumoniae (n = 14, 29.2%) and group A streptococcus (n = 10, 20.8%). Multidrug resistance was not associated with complication type. Surgical management included myringotomy ± tympanostomy tube placement in 46 (95.8%) patients (the only surgery in 10), drainage of subperiosteal abscess without mastoidectomy in 18 (37.5%) patients, and mastoidectomy in 21 (43.8%) total patients. Patients presenting with intracranial complications were the most likely to undergo a mastoidectomy. Anticoagulation was used in the management of nine of 14 (64.3%) patients presenting with sigmoid sinus thrombosis. Neurosurgical interventions (n = 7, 14.6% patients) were primarily performed to manage increased intracranial pressure.

CONCLUSIONS

Subperiosteal abscess was the most common complication of acute mastoiditis, and when occurring as the sole complication was successfully managed with antibiotics and surgical intervention that did not include mastoidectomy. Epidural abscess and sigmoid sinus thrombosis were more prevalent than reported in prior series and were managed more aggressively. These patients were more likely to need neurosurgical interventions.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2321-2327, 2017.

Cochlear changes in serous labyrinthitis associated with silent otitis media: A human temporal bone study

PURPOSE

To determine histopathological findings in the cochlea of human temporal bones with serous labyrinthitis.

MATERIALS AND METHODS

We compared human temporal bones with serous labyrinthitis (20 cases) associated with silent otitis media and without serous labyrinthitis (20 cases) to study location of serous labyrinthitis, the degree of endolymphatic hydrops, number of spiral ganglion cells and hair cells, loss of fibrocytes in the spiral ligament, and areas of the spiral ligament and stria vascularis.

RESULTS

The serous labyrinthitis caused significant loss of outer hair cells in the lower basal (P=0.006), upper basal (P=0.005), and lower middle (P=0.011) cochlear turns, and significant increase in the degree of endolymphatic hydrops than the control group (P=0.036). No significant difference was found in the loss of inner hair cells, in the number of spiral ganglion cells and fibrocytes in the spiral ligament, and in areas of the stria vascularis and spiral ligament (P>0.05).

CONCLUSIONS

Serous labyrinthitis resulted in significant loss of outer hair cells and significant increase in the degree of endolymphatic hydrops.

Multidisciplinary care of a paediatric patient with Gradenigo's syndrome

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.

Complications of Pediatric Otitis Media

Objective

Otitis media (OM) is a common diagnosis in the pediatric population that is usually managed on an outpatient basis. A small proportion of children are admitted due to a complex disease course. The aim of this study was to investigate the demographics of those patients and the resources utilized during their admissions.

Study Design

Retrospective review based on the 2009 Kids’ Inpatient Database.

Setting

Nationwide administrative database.

Subjects and Methods

A review based on the 2009 Kids’ Inpatient Database was conducted. Inclusion criteria were clinical modification codes for OM ( ICD-9 code 382). Data recorded included patient demographics, concurrent discharge diagnosis codes, length of stay, total charges, and frequency of procedures performed.

Results

There were 61,783 (92,548 nationally weighted) admissions with OM, which were analyzed. The average age (SD) for the patients was 2.18 (3.49) years, and the average length of stay was 2.88 days. The majority (80.75%) of patients did not have to undergo a procedure during admission, whereas a small proportion (5.4%) underwent a major operating room procedure. There were 21 deaths recorded (0.03%). A diagnosis of mastoiditis, meningitis, venous sinus thrombosis, or intracranial abscess was associated with significantly increased length of stay, incidence of procedures, and total cost of admission.

Conclusions

Complicated pediatric OM remains of concern requiring prompt and thorough management. Major complications include mastoiditis and meningitis, and unfortunately, fatalities still occur in patients with OM. An understanding of resource utilization and socioeconomic implications can identify and drive opportunities for targeted quality improvement.

Pott's puffy tumor: a rare complication of acute otitis media in child: a case report

To describe a rare case of Potts' puffy tumor (PPT) in the zygomatic area, which developed as a complication of acute otitis media in a 6-year-old child. To date, only one case of PPT has been described in the literature as a complication of latent mastoiditis in an adult, and one case of PPT as a complication of acute mastoiditis in a 10-year-old child. Urgent surgical intervention, including evacuation of the purulent lesion, removal of inflamed soft tissue and osteolysis of the involved bone, and antromastoidectomy, intravenous treatment with broad-spectrum antibiotics, including G+, G-, anaerobes and fungi, and local therapy.

The impact of the Italian guidelines on antibiotic prescription practices for acute otitis media in a paediatric emergency setting

Background

Acute otitis media (AOM) is one of the most common childhood infectious diseases. The recent Italian Pediatric Guidelines for the treatment of AOM constitutes a step forward in the management of children with uncomplicated AOM. The aim of this study was to evaluate antibiotic prescription patterns for AOM in a Pediatric Emergency Department (PED) after those guidelines were introduced and to assess the relationship between implementation of the “watchful waiting” strategy and the incidence of acute mastoiditis in the PED.

Methods

This retrospective study was conducted between 1st January 2007 to 31st December 2013 at the PED of the University of Modena and Reggio Emilia in Modena (Italy). All children between 0 and 14 years who were examined because of symptoms and/or signs of AOM and acute mastoiditis were enrolled. Pearson’s chi-squared test was used to evaluate if introduction of the Italian Paediatric Guidelines was associated with a reduction in the antibiotic prescription pattern in children with AOM and/or with an increase in mastoiditis frequency.

Results

4,573 (89.4%) patients were included in our analysis, antibiotics were prescribed to 81% cases of the children diagnosed with AOM. The frequency of antibiotic prescribing continued to be stable after the Italian guidelines were introduced (82% versus 81%).

Forty children were admitted to hospital with a diagnosis of acute mastoiditis. Our study did not find any association between the number of cases of acute mastoiditis and the percentage of patients treated with antibiotics; the annual incidence of mastoiditis before and after the new guidelines were published was, in fact, stable.

Conclusions

Despite the diffusion of clinical guidelines recommending a “watchful waiting” approach for children with AOM, the antibiotic prescription rate continues to be high. It appears to be more difficult to impact the percentage of cases for which antibiotics are prescribed than the type of antibiotic that is utilized. In view of these findings, a close follow-up control by the primary care paediatrician or a scheduled follow-up appointment at the PED and incisive campaigns to promote parents’ awareness of proper antibiotic use appear to be warranted.

Intratemporal and intracranial complications of acute otitis media in a pediatric population

OBJECTIVE

To review all cases intratemporal and intracranial complications of acute otitis media (AOM) in infants and children from 1998 to 2013.

METHODS

Retrospective chart review of 109 consecutive patients admitted for complications of AOM during a 15-year period at a tertiary-care children's hospital. The main outcomes are: (1) complications of AOM, (2) bacteriology, (3) management strategies.

RESULTS

In our population, complications included mastoiditis (86.1%), subperiosteal abscess (38%), facial nerve palsy (16.7%), sigmoid sinus thrombosis (8.3%) and epidural abscess (7.4%). Other complications included post-auricular cellulitis, otic hydrocephalus and elevated intracranial pressure, internal jugular thrombosis, cranial nerve VI palsy and Gradenigo's syndrome, labyrinthine fistula, sensorineural hearing loss, and cerebellar infarct. Sixty-one patients (56%) received antibiotics prior to presentation. Cultures revealed Streptococcus pneumoniae in 36 patients (33.3%), other bacteria in 30 patients (27.8%), and "no growth" in 33 patients (30.5%). Nine patients (8.3%) did not undergo culture. Of the patients with S. pneumoniae, 20 cultures (55%) were found to be multidrug-resistant. Eleven patients (10.2%) were treated non-surgically, 31 (31%) were treated with myringotomy and intravenous antibiotics. Forty patients (97.5%) presenting with subperiosteal abscess required mastoid surgery. Thirteen of 18 (72.2%) patients with facial paralysis had full recovery. Eight of 10 (80%) patients with epidural abscess empyema required mastoid surgery and incision and drainage of the abscess.

CONCLUSION

Complications of AOM are uncommon, yet continue to have potentially serious consequences. The bacteriology in this population reveals an increasing trend of multi-drug resistant S. pneumoniae as the causative organism.

[Facial nerve paralysis secondary to acute otitis media]

OBJECTS

To discuss clinical presentation and therapeutic approaches of facial paralysis in acute otitis media.

METHODS

We present five cases of facial palsy in children with acute otitis media managed in our ENT department during a period of 12 years (2001-2012).

RESULTS

The mean age was 14.2 years; sex ratio was 0.66. All patients presented with a facial asymmetry, but only 3 of them had otalgia before the onset of facial asymmetry. The facial palsy delay was 3.3 days. The ear examination showed that the tympanic membrane was congestive in 4 patients, associated with a bulging in 2 patients, and a small perforation in one patient. Our patients presented grade III to IV initial facial palsy according to House and Brackmann staging. Computed tomography scan revealed a dehiscence of the bony facial canal in one patient. Antibiotic therapy associated with intravenous corticosteroids was administered in all patients. All patients underwent a facial kinesis therapy. A progressive improvement of facial palsy was observed in 4 patients and complete recovery of facial function in one case.

DISCUSSION

Conservative treatment associating intravenous antibiotic and corticosteroids with or without myringotomy is the standard approach.

Cost of cholesteatoma care at a tertiary medical center

OBJECTIVE

Estimate the available direct cost of cholesteatoma care in a university practice.

STUDY DESIGN

Retrospective review of both physician and hospital financial data during a recent 3-year period.

SETTING

University-based tertiary referral medical system.

PATIENTS

Adults (≥ 18 yr old) with cholesteatoma.

INTERVENTION(S)

Financial information associated with both physician and hospital encounters were analyzed in a deidentified manner.

MAIN OUTCOME MEASURE(S)

Frequency and type of encounter, charges, collections, and payers were tabulated.

RESULTS

Approximately 949 physician encounters (817 clinic, 130 surgical, and 2 inpatient) among 344 patients resulted in greater than $700, 000 in charges and greater than $211,000 in receipts (≈ 30% rate of collection). The average physician charge per patient per year was approximately $1,600. About 259 hospital encounters among 171 patients resulted in greater than $1.8 million in charges and greater than $520,000 in receipts (≈ 28% collection rate). The average hospital charge per patient per year was ∼$10,000. For physician encounters, managed care (37%) and Medicare (25%) were the most common payers, whereas 17% were uninsured. For hospital encounters, managed care (28%) and Medicare (14%) were the most common payers, whereas 24% were uninsured.

CONCLUSION

The direct cost of care for patients with cholesteatoma is significant. The current treatment paradigm for this chronic disorder results in repeated health care system access and associated direct (and unmeasured indirect) expenses. Future treatment paradigms should be designed to improve disease-specific quality of life while mitigating this financial impact.

Petrositis With Bilateral Abducens Nerve Palsies complicated by Acute Otitis Media

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.

Unusual presentation of acute otomastoiditis with petrositis

The anatomical relationships of the middle ear, the mastoid air cells, the temporal bone and intracranial structures can lead to invasive infections. Acute mastoiditis is the most common intratemporal complication of acute otitis media. Timely management includes antimicrobial therapy, imaging including ultrasound and/or computed tomography, surgical consultation and intervention. There are insufficient data to provide an evidence-based diagnostic tool for acute mastoiditis. Clinical, laboratory and microbiological differences between children with simple and complicated mastoiditis will be explored after case presentation of a 5-year-old boy with fever and a tender, soft-tissue swelling over the left zygomatic arch.

Malocclusion in children caused by temporomandibular joint effusion

Two unusual cases of temporomandibular joint effusion in children are presented. The differential diagnosis, radiographic imaging, treatment, and possible etiologies are described.

Clinical and microbiologic features guiding treatment recommendations for brain abscesses in children

BACKGROUND

There are no guidelines for the management of brain abscesses in children, and there is a paucity of recent data describing clinical and microbiologic features. We aimed to identify factors affecting outcome to inform antibiotic recommendations.

METHODS

From 1999 to 2009, 118 children presented with brain abscesses to 4 neurosurgical centers in the United Kingdom. Clinical, microbiologic and treatment data were collected.

RESULTS

The commonest preceding infection was sinusitis, with 59% of all children receiving antibiotics before diagnosis. Nonspecific symptoms were common, with only 13% having the triad of fever, headache and focal neurological deficit. Time between symptom onset and diagnosis varied widely (median, 10 days; range, 0-44). Magnetic resonance imaging was more frequently diagnostic than computed tomography. The most frequent organisms were Streptococcus milleri (38%), except after penetrating head injury or neurosurgery, for which Staphylococcus aureus was most common. The commonest empiric antibiotics were ceftriaxone/cefotaxime and metronidazole, which offered effective antimicrobial therapy in up to 83% of cases. Metronidazole added benefit in a maximum of 7% of cases, with ceftriaxone/cefotaxime alone sufficient in at least 76% and in all cases with cyanotic congenital heart disease or meningitis. A carbapenem would have been effective in 90%. The case fatality rate was 6% (33% in the immunocompromised). Long-term neurological sequelae affected 35%. Age younger than 5 years and a Glasgow Coma Scale score ≤8 were associated with poor outcome at 6 months.

CONCLUSIONS

We recommend ceftriaxone/cefotaxime and metronidazole as empiric treatment, although metronidazole may be unnecessary in many cases, with antistaphylococcal cover in cases of head trauma. Meropenem potentially would be a better choice in the immunocompromised. A prospective study of intravenous and oral treatment guided by clinical improvement is required beause 1-2 weeks of intravenous antibiotics during a total of 6 weeks may be sufficient in children.

Mastoid subperiosteal abscess in children: drainage or mastoidectomy?

OBJECTIVE

To evaluate the management of mastoid subperiosteal abscess using two different surgical approaches: simple mastoidectomy and abscess drainage.

METHOD

The medical records of 34 children suffering from acute mastoiditis with subperiosteal abscess were retrospectively reviewed. In these cases, the initial surgical approach consisted of either myringotomy plus simple mastoidectomy or myringotomy plus abscess drainage.

RESULTS

Thirteen children were managed with simple mastoidectomy and 21 children were initially managed with abscess drainage. Of the second group, 12 children were cured without further treatment while 9 eventually required mastoidectomy. None of the children developed complications during hospitalisation, or long-term sequelae.

CONCLUSION

Simple mastoidectomy remains the most effective procedure for the management of mastoid subperiosteal abscess. Drainage of the abscess represents a simple and risk-free, but not always curative, option. It can be safely used as an initial, conservative approach in association with myringotomy and sufficient antibiotic coverage, with simple mastoidectomy reserved for non-responding cases.

Mastoiditis and Gradenigo's Syndrome with anaerobic bacteria

BACKGROUND

Gradenigo's syndrome is a rare disease, which is characterized by the triad of the following conditions: suppurative otitis media, pain in the distribution of the first and the second division of trigeminal nerve, and abducens nerve palsy. The full triad may often not be present, but can develop if the condition is not treated correctly.

CASE PRESENTATION

We report a case of a 3-year-old girl, who presented with fever and left-sided acute otitis media. She developed acute mastoiditis, which was initially treated by intravenous antibiotics, ventilation tube insertion and cortical mastoidectomy. After 6 days the clinical picture was complicated by development of left-sided abducens palsy. MRI-scanning showed osteomyelitis within the petro-mastoid complex, and a hyper intense signal of the adjacent meninges. Microbiological investigations showed Staphylococcus aureus and Fusobacterium necrophorum. She was treated successfully with intravenous broad-spectrum antibiotic therapy with anaerobic coverage. After 8 weeks of follow-up there was no sign of recurrent infection or abducens palsy.

CONCLUSION

Gradenigo's syndrome is a rare, but life-threatening complication to middle ear infection. It is most commonly caused by aerobic microorganisms, but anaerobic microorganisms may also be found why anaerobic coverage should be considered when determining the antibiotic treatment.

Otitis media

Otitis media represents a broad spectrum of disease, which include acute otitis media and otitis media with effusion. As immunization with the pneumococcal conjugate vaccine has become more widespread, the microbiological landscape of otitis media has changed, which affects the treatment options facing clinicians worldwide. This review discusses the diagnosis and medical management of acute and chronic suppurative otitis media, the changes noted over the past decade, and briefly expounds on the surgical management of their severe complications.

Acute otitis media-induced petrous apicitis presenting as the Gradenigo syndrome: successfully treated by ventilation tube insertion

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.

Facial nerve palsy in childhood

Facial nerve palsy in children is usually idiopathic but can also result from many conditions such as neoplasias, systemic diseases, or congenital anomalies with poor prognosis. Children with idiopathic facial palsy (Bell's palsy) have a very good prognosis, while treatment with prednisone does not certainly improve the outcome. The causes of facial nerve palsy in childhood differ from those in adults. A detailed investigation and differential diagnosis are recommended for facial palsy in children.

Unusual complication of otitis media with effusion: facial nerve paralysis

Facial nerve paralysis (FNP) is a very rare complication of otitis media with effusion (OME). There are few patients with OME and FNP in the literature. A 5-year-old girl was admitted to our department with right facial weakness. Right FNP and right OME were diagnosed on the examination. After medical treatment and ventilation tube insertion, FNP completely resolved. The symptoms, signs, and management of this patient are presented.

Therapeutic approach to Gradenigo's syndrome: a case report

Introduction

Traditional management of Gradenigo's syndrome requires aggressive and radical surgery without any attempt to preserve hearing. Recent reports, however, describe a successful outcome after conservative surgical intervention without labyrinthectomy. A similar outcome has also been reported in patients who were only prescribed with antibiotics and did not undergo myringotomy.

Case presentation

We report the case of a 24-year-old Caucasian Greek woman with Gradenigo's syndrome who was treated by draining her petrous apex via an infralabyrithine approach between her posterior semicircular canal and the jugular bulb. Her inner ear was not sacrificed during the procedure. She presented pre-operatively with ipsilateral conductive hearing loss, which recovered completely four weeks after the surgery.

Conclusions

Patients with Gradenigo's syndrome may be successfully treated with a combination of long-term permanent drainage and ventilation of the apical cells with corresponding hearing preservation. This can be achieved via a combination of transmastoid, infralabyrinthine and suprajugular approaches, if such would be allowed by the anatomy of the region or if there is enough space between the posterior semicircular canal and the jugular bulb.