Abducens nerve palsy complicated by inferior petrosal sinus septic thrombosis due to mastoiditis

Surgical management of mastoiditis with intratemporal and intracranial complications in children. Outcome, complications, and predictive factors

INTRODUCTION

Intratemporal or intracranial complications of acute mastoiditis are often of significant severity, can be life-threatening, and require prompt and usually aggressive treatment. This study focused on analyzing the outcomes and complications of different surgical techniques used in intracranial and intratemporal complications of acute mastoiditis, the most common complication of acute otitis media.

METHODS

A retrospective study of pediatric patients with mastoiditis with intratemporal and intracranial complications was designed at the Niño Jesús University Children's Hospital in Madrid, Spain, from 2005 to 2021.

RESULTS

Of 417 patients with mastoiditis, 112 patients developed intratemporal and intracranial complications, with subperiosteal abscess being the most frequent complication. The most frequently isolated pathogens were Streptococcus pneumoniae, Streptococcus pyogenes, and Fusobacterium necrophorum. The most used surgical technique was myringotomy with placement of transtympanic drainage, in 86.6% of all cases. In patients with intracranial complications, neurosurgical procedures were necessary for 19.2%, with craniotomy with mastoidectomy being the most frequent. Most of the cases evolved favorably, and only 5.4% of the patients required surgical reintervention, being more frequent in intratemporal complications. In terms of complications, we found cases of neutropenia in 3.6%, neurological sequelae in 5.4%, and permanent hearing loss in 2.7%.

CONCLUSIONS

There was a favorable evolution with a low incidence of reoperation and sequelae within our series. The surgical technique of choice correlated with the severity of the complication. If the mean size of the abscess exceeds 20 mm, incision and drainage, along with myringotomy and tube placement, should be considered as the initial treatment. Closed mastoidectomy should be reserved for deteriorating of clinical evolution or acute mastoiditis with intracranial complications. Intracranial and multiple concomitant complications were associated with a more extended hospital stay, ICU occupancy, neurosurgical intervention, and risk of neurological sequelae and neutropenia. Conversely, intratemporal complications may result in permanent hearing loss.

The effect of morphological variability of Dorello's canal on surgical procedures - a review

Dorello's canal is an arched structure of bone-fibrous character located in the petroclival venous confluence atop the petrosal bone in the petroclival region. It is bordered by the petrosphenoidal ligament, the petrous part of the temporal bone and the lateral border of the upper part of clivus. Its content in the vast majority of variants comprises the abducens nerve, the inferior petrosal sinus, the venous drainage and the dorsal meningeal artery or its medial branch. With the development of microsurgical techniques, this area has gained huge clinical importance, mainly concerning the order in which the above-mentioned elements (especially the position of the abducens nerve) are arranged in relation to each other. These structures appear in different variant forms and necessitate an individual clinical approach. The main purpose of this review is to present condensed information about possible intercorrelations among them and to indicate, on the basis of the available literature and research, possible surgical approaches and the need to consider the variability when treatments in this region are planned.

Acute mastoiditis complicated by cerebral venous sinus thrombosis in children

AIM

Diagnosis and management of complicated mastoiditis in childhood are still controversial. We investigated the clinical manifestations, evaluation and management of children with mastoiditis complicated with cerebral venous sinus thrombosis.

METHODS

Retrospective cohort study that included all children admitted for acute mastoiditis over the last 5 years. Children were divided in two groups based on the presence or not of venous sinus thrombosis. Clinical, laboratory, imaging and management data were retrieved and compared.

RESULTS

Overall, 20 children with acute mastoiditis were included, of whom 5 had magnetic resonance imaging-confirmed cerebral venous sinus thrombosis and elevated intracranial pressure (ICP). In all complicated cases, neurological signs rather than mastoiditis signs, prevailed. The more prominent neurologic signs observed were lethargy (60%), nuchal rigidity (60%), abducens nerve palsy (60%) and ataxic gait (20%). Treatment consisted of intravenous antibiotics combined with anticoagulation. Surgery was performed in four children (4/5). Complicated cases had prolonged symptoms prior to admission (p 0.002), presented with neurologic signs and symptoms (p < 0.001), underwent more often lumbar puncture (p < 0.001) and brain imaging (p < 0.001), and were treated with prolonged courses of antibiotics and surgery (<0.001), compared to children with uncomplicated mastoiditis.

CONCLUSION

Neurological signs and symptoms and elevated ICP dominate in children with mastoiditis complicated with thrombosis. Brain imaging is essential for early diagnosis of cerebral venous sinus complications and appropriate management.

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.

Abducens nerve palsy due to inferior petrosal sinus thrombosis

Isolated unilateral abducens nerve palsy is usually due to ischemia, trauma or neoplasm. Dorello's canal is the space between the petrous apex and superolateral portion of the clivus, bound superiorly by Gruber's ligament. The abducens nerve travels with inferior petrosal sinus (IPS) though the Dorello's canal before entering the cavernous sinus. A 31-year-old man presented with neck pain, and binocular horizontal diplopia, worse looking towards left and at distance. He had a history of intravenous drug abuse but no history of hypertension or diabetes. On examination, he had complete left 6th nerve palsy with normal fundi, pupils, and other cranial nerves. Methicillin-resistant Staphylococcus aureus bacteremia was detected with naïve tricuspid valve endocarditis and multiple septic emboli to lungs with infarcts. His cerebrospinal fluid was normal. MRI of the brain was normal. MRV of head and neck showed thrombosis of the left internal jugular vein, left sigmoid sinus and left inferior petrosal sinus with normal cavernous sinus and no evidence of mastoiditis. He was treated with broad spectrum antibiotics. He was not anticoagulated for fear of pulmonary hemorrhage from pulmonary infarcts. Although cerebral venous sinus thrombosis commonly presents with elevated intracranial pressure, isolated ipsilateral 6th nerve palsy from its compression in Dorello's canal due to thrombosis of the ipsilateral inferior petrosal sinus is extremely rare. To our knowledge, only two patients have been reported with isolated abducens palsy due to IPS thrombosis; one caused by septic emboli and the other developed it during IPS cortisol level sampling.

Dangerous diplopia: A case of pansinusitis

PURPOSE

To report a case of pansinusitis after swimming in a common pool.

CASE REPORT

Acute sinusitis is ranked the fifth-most common indication for antibiotic prescriptions.2 Although sinusitis is often diagnosed clinically, cases that are resistant to conventional antibiotic therapy or recurrent cases may require diagnostic imaging in order to confirm the diagnosis. The complications of sinusitis, though rare, may lead to serious consequences if not diagnosed and treated early. We report a 33-year old man with pansinusitis presenting with a sudden onset of peripheral gaze diplopia associated with progressive frontal headache. His symptom resolved completely after he was given intravenous antibiotics and a nasal decongestant.

Acute mastoiditis--the role of radiology

Acute mastoiditis is a commonly occurring condition in children and adults, and one that most radiologists will come across at some point during their on-call duties. Acute mastoiditis is usually clinically apparent. However, the complications, especially the intracranial ones, can be more insidious and may have fatal consequences. Therefore, it is imperative that the radiologist is well versed in identifying these. Local spread of infection from the mastoids and middle ear cleft may occur via four routes: bone erosion, thrombophlebitis, periphlebitis, and via the anatomical pathways. The role of radiology is largely to demonstrate the complications of mastoiditis, which can be clinically occult and are often serious; this article will highlight these complications.