petrositis

Petrositis: A Serious Infection of the Temporal Bone

Petrositis, also known as petrous apicitis, is a rare but serious infection that affects the petrous portion of the temporal bone in the skull. This infection can be life-threatening if left untreated.

Causes and Symptoms

The infection typically occurs when bacteria from a middle ear or mastoid infection spread to the petrous cells of the temporal bone through vascular canals or bone resorption. The surrounding nerves (cranial nerves V through VII) may be affected, causing related pain and palsies.

Symptoms of petrositis are usually subtle and may include:

• Fever
• Occipital headache
• Ear pain
• Deep facial pain
• Retro-orbital pain
• Diplopia (double vision)

Complications and Treatment

Petrositis is a very serious complication that requires immediate surgical intervention via mastoidectomy with an extratemporal approach into the petrous air cells, followed by long-term IV antibiotic therapy. If left untreated, it can lead to severe complications, including:

• Neural compromise
• Facial paralysis
• Hearing loss
• Meningitis

Prevalence and Demographics

Petrositis occurs less commonly than mastoiditis because only 30% of petrous bones have air cells extending to the apex. It is more common in patients with poor resistance, such as old diabetics.

References:

• [1] Petrositis most often refers to infection of the petrous portion of the temporal bone... (Source: #11)
• [2-3] The surrounding nerves (cranial nerves V through VII) may then be affected by the local inflammatory process, causing related pain and palsies. (Source: #10)
• [4] Petrositis is a very rare complication of AOM or OME... (Source: #13)
• [5-6] Symptoms of petrositis are usually subtle... (Source: #8 & #15)

Symptoms of Petrositis

Petrositis, also known as petrous apicitis or Gradenigo's syndrome, is a rare but serious complication of acute otitis media and mastoiditis. The symptoms of petrositis can be subtle and may not always present with the classic triad of retroorbital pain, lateral rectus (CN VI) palsy, and otorrhea.

Common Symptoms:

• Deep facial pain due to inflammation of the adjacent dura and trigeminal nerve in Meckel's cave [3]
• Abducens nerve palsy (lateral rectus muscle weakness), leading to diplopia (double vision) [4]
• Headache, often described as spasmodic and felt deep behind the ear [4]
• Evidence of middle ear infection
• Trigeminal pain

Other Possible Symptoms:

• Facial paralysis
• Hearing loss
• Tinnitus (ringing in the ears)
• Vertigo (spinning sensation)
• Headache
• Syncope (fainting)
• Stroke

Classic Signs of Gradenigo's Syndrome:

• Otorrhea (ear discharge)
• Facial pain
• Horizontal diplopia (double vision)

It is essential to note that these symptoms can be similar to those of other conditions, and a proper diagnosis by an ear, nose, and throat (ENT) specialist or neurologist is crucial for accurate treatment.

Diagnostic Tests for Petrositis

Petrositis, an infection of the petrous portion of the temporal bone, requires prompt and accurate diagnosis to initiate effective treatment. The following diagnostic tests are commonly used to diagnose petrositis:

• Computed Tomography (CT) imaging: CT scans are the preferred imaging modality for diagnosing petrositis, as they can evaluate bone involvement and identify lesions in the petrous temporal bone [7][15].
• Magnetic Resonance Imaging (MRI): MRI may also be used to assess bone involvement and identify lesions in the petrous temporal bone.
• Complete Blood Count (CBC): A CBC is a crucial diagnostic test that evaluates the white blood cell count, which can indicate the presence of an infection [11][13].
• Electrolyte tests: Electrolyte tests, such as sodium, potassium, and chloride levels, may be ordered to evaluate electrolyte imbalances associated with petrositis.
• Blood glucose determination: Blood glucose levels may also be evaluated to assess for potential metabolic disturbances.

Additional Diagnostic Considerations

In addition to these diagnostic tests, a thorough clinical evaluation is essential in diagnosing petrositis. This includes:

• History of otitis media, mastoiditis, or petrositis: A history of previous ear

Conservative but Efficient Method

Petrositis, a rare and fatal complication associated with otitis media, can be effectively treated with drug therapy alone in some cases [10]. The use of sensitive antifungal drugs has been reported to be a conservative but efficient method for treating petrositis caused by fungal infections [11].

Antibiotic Treatment

Intravenous antibiotics such as ceftriaxone and vancomycin have been used to treat petrositis, often in combination with other medications like metronidazole [5][8][9]. This treatment approach has shown promise in resolving the infection without the need for surgical intervention.

Efflux Inhibitors

Research on the treatment of drug-resistant fungi is ongoing, and studies have explored the use of efflux inhibitors such as P22CP to combat these infections [10].

Pathogenic Reference

Molecular Next-Generation Sequencing (mNGS) can provide a pathogenic reference for diagnosing petrositis, particularly when antibiotic therapy is not effective against fungal infections or drug-resistant fungal infections cases [11][13].

While surgery may still be necessary in some cases, drug treatment remains a conservative and efficient method for treating petrositis, especially when used in conjunction with mNGS for pathogenic reference.

References: [10] - Petrositis is a rare and fatal complication associated with otitis media. It is most likely caused by bacterial infections, but in some cases it is caused by fungal infections. [11] - Drug treatment is conservative but efficient method in this case. mNGS can provide pathogenic reference... [5] - The patient was treated with sensitive antifungal drugs. [8] - The patient was given intravenous ceftriaxone (2 g/day) and vancomycin (600 mg/3 per day) for 3 weeks, metronidazole (400 mg/3 per day) for 1 week... [9] - The patient was given intravenous ceftriaxone (2 g/day) and vancomycin (600 mg/3 per day) for 3 weeks, metronidazole (400 mg/3 per day) for 1...

Differential Diagnosis of Petrositis

Petrositis, also known as apical petrositis or Gradenigo’s syndrome, is a serious infection of the petrous apex. The differential diagnosis of petrositis includes various conditions that can present with similar symptoms and imaging features.

• Congenital entities: Asymmetric fatty marrow, cholesteatoma, and congenital petrous apex lesions are considered in the differential diagnosis [4].
• Infection: Apical petrositis is a serious infection of the petrous apex, which can spread from the middle ear and mastoid to the petrous cells of the temporal bone through vascular canals or bone resorption [11].
• Benign obstructive processes: Effusion, mucocele, cholesterol granuloma, and other benign lesions can cause similar symptoms and imaging features as petrositis [4].
• Malignant tumors: Chordoma, chondrosarcoma, osteosarcoma, plasmacytoma, and other malignant tumors should be considered in the differential diagnosis of destructive petrous apex lesions [7].
• Other conditions: Otitis externa, jugular paraganglioma, mucocoele of the petrous apex, and other rare conditions can also present with similar symptoms and imaging features as petrositis [10, 12].

Key Symptoms and Signs

The diagnosis of petrositis is typically made by CT or MRI scans. Key symptoms and signs include:

• Facial pain
• Cranial nerve six palsy (abducens nerve)
• Ear pain
• Destructive malignant tumors can cause similar symptoms and imaging features [7]

References

[4] Jan 11, 2024 - There is a wide differential diagnosis of petrous apex lesions: pseudolesions, asymmetrical marrow/asymmetrical pneumatization, petrous apex cephalocele. [7] Apical petrositis is a serious infection of the petrous apex. A well-described, although relatively rare, clinical presentation includes facial pain, cranial nerve six palsy, and ear pain [7]. [10] Petrositis occurs when infection from the middle ear and mastoid spread to the petrous cells of the temporal bone by vascular canals or bone resorption [11]. [11] The surrounding nerves (cranial nerves V through VII) may then be affected by the local inflammatory process, causing related pain and palsies [11].