Petrositis With Bilateral Abducens Nerve Palsies complicated by Acute Otitis Media
A 8-year-old girl was admitted to our pediatric department with a 3-week history of headache and diplopia. She had visited a local clinic due to otorrhea of left side and taken medication under the diagnosis of left AOM. After a few days, otorrhea disappeared but headache and diplopia were worsened. Her past medical history was significant only for left convergent strabismus. At admission, physical examination showed restricted lateral gaze of both eyeballs and diplopia at central gaze, secondary to clearly apparent both abducens nerve palsies (). Facial motor examination was normal. The left tympanic membrane was amber and right tympanic membrane was intact. There was no fever, although she claimed that she had high fever up to 38.9℃ before she took medication at the local clinic. Her headache was located at left temporal area at the initial stage but migrated to frontal and then to whole head. The ophthalmologic examination showed bilateral optic disc swelling (). Laboratory tests showed a white blood cell count of 6, 290 mm3 with 67% neutrophils, and the C-reactive protein was 0.3 mg/L, and erythrocyte sedimentation rate (ESR) 6 mm/hour. Under the impression of meningitis at the pediatric department she took brain magnetic resonance imaging (MRI), spinal tapping, temporal bone computed tomography (CT), and bone scan. Her brain MRI showed a diffuse inflammatory process in the left mastoid air cells with invasion of the left petrous bone (). Temporal bone CT showed soft tissue densities at left mastoid, middle ear, and well-developed petrous apex cells (). The cerebrospinal fluid examination was normal, and bone scan showed increased uptake of the left mastoid and petrous bones. Diagnosis of left petrositis and bilateral abducens nerve palsies was made, and intravenous antibiotic treatment with ceftriaxone (1 g/day), clindamycin (300 mg/day) was initiated. After 9 days of intravenous antibiotics, consultation and transfer to otolaryngology department was done due to continuous headache and diplopia. Pure tone audiometry was done and showed air-bone gap of 10 dB on left ear. On physical examination, restricted lateral gaze on both sides due to abducens nerve palsies of both side was noted. Left tympanic membrane was amber and ventillation tube insertion was performed and serous profuse discharge in the middle ear was sent for culture. No bacteria was identified. Intravenous antibiotics (ceftriaxone, clindamycin) were continuously administered and topical ear drops were applied. On the 16th hospital day, diplopia was improved and the field of diplopic vision was shortened from 10 cm to 2 cm length (), but intermittent spiking fever up to 38.3℃ occurred, and intravenous amikacin was added. On the 19th hospital day, the fever continued and follow-up temporal bone CT with contrast enhance, H1N1 PCR for H1N1 flu which was common at the time, general laboratory studies and pediatric consultation was done. On temporal bone CT with contrast enhancement, remaining soft tissue densities at mastoid and petrous area with improving petrositis was noted (). And with negative H1N1 PCR and high AST/ALT of 617/365 IU/L, under the diagnosis of drug fever, she was transfered to the pediatric department, on the 21th hospital day when diplopia disappeared. Antibiotic was changed to intravenous vancomycin, and fever subsided with AST/ALT of 40/78 IU/L on the 30th hospital day. The strabismus returned to preadmission state, and the patient was finally discharged (). After two weeks at the out-patient department, follow-up temporal bone CT was taken and disappearance of opacification and improved aeration at left petrous apex area were noted (). There was also improvement of bilateral papilledema six weeks later of admission ().