CASE 1704 Published on 31.03.2006

Petrous apicitis with Gradenigo's syndrome

Section

Head & neck imaging

Case Type

Clinical Cases

Authors

Monzón M, Puy R, Blanch J, Ribó JL, Badosa J

Patient

6 years, male

Categories
No Area of Interest ; Imaging Technique CT, MR
Clinical History
The patient presented with sudden onset diploplia and stiff neck following 3 weeks of headache.
Imaging Findings
The patient presented with a sudden onset of diplopia and stiff neck, following 3 weeks of headache. An examination of the eyeball movements revealed a left abductor nerve paresis. CT and MRI examinations of the cranium were performed, which revealed left petrous apex destruction associated with a small epidural collection. It was diagnosed as petrous apicitis with symptoms of Gradenigo's syndrome.
Discussion
The CT examination when done showed a small epidural enhanced left petrous collection with downward extension to the superior pharyngeal mucosal space, extensive destruction of the ipsilateral petrous apex and opacification of the tympanic cavity and mastoid air cells, with mastoidal sclerosis. The MRI showed the left petrous apex lesion, which was hypointense as seen on T1-weighted images, hyperintense when seen on T2-weighted images and enhanced by using gadolinium, and also demonstrated the small infracranial extension. CT and MRI are highly sensitive in detecting petrous apex lesions. As in this case, they permit the identification of apical osteomyelitis surrounded by a phlegmon collection. When the petrous apicitis is large enough, it can injure the VI cranial nerve where it passes through the petrous apex in Dorello's canal, on its way to the orbit via the cavernous sinus. Then, the patient presents with the symptoms of Gradenigo's syndrome: otitis media, deep facial pain along the distribution of the trigeminal nerve and ipsilateral abducens nerve paralysis (1,2). The stiff neck of this patient could have been related to the download skull base lesion. The differential diagnosis of a petrous apex lesion in the paediatric population may include a cholesterol granuloma, primary cholesteatoma, histiocytosis X, and rarely a tumour such as a rhabdomyosarcoma, neuroblastoma or metastasis (2,3). A cholesterol granuloma looks like an expansive mass, but the haemoglobin breakdown products and cholesterol content will show a hyperintense lesion in both T1- and T2-weighted images. Primary cholesteatomas are more commonly found in the middle ear cavity, as a globular mass with bony scalloping and without contrast enhancement. Histiocytosis of Langerhan's cells frequently affects the cranial skull with single or multiple osteolytic areas, sometimes surrounded by a small solid soft-tissue mass. A petrous apex location is known to be uncommon. Rhabdomyosarcoma and neuroblastoma are malignant tumours in which soft tissue is affected rather than the bone (2,3). The patient was treated with antibiotics (cefotaxime and vancomycin) and drainage of the middle ear exudate was done by performimng a myringotomy. He made a complete recovery following this treatment.
Differential Diagnosis List
Petrous apicitis with Gradenigo's syndrome.
Final Diagnosis
Petrous apicitis with Gradenigo's syndrome.
Case information
URL: https://eurorad.org/case/1704
DOI: 10.1594/EURORAD/CASE.1704
ISSN: 1563-4086