Chronic petrous pyramid abscess presenting as a cerebellopontine angle mass Case report
FRANZ E. GLASAUER, M.D., AND WALTER GRAND, M.D.
Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York ~" The authors present the case of a 5-year-old boy with a chronic petrous pyramid abscess and without a history of otitis media. Treatment by posterior fossa exploration and drainage with antibiotics was successful. KEY WORDS 9 chronic abscess 9 posterior fossa
HRONIC abscess or osteomyelitis of the petrous bone as a result of direct or venous extension of acute suppuration, sinusitis, or mastoiditis is rare and has been almost unknown since the general use of antibiotics in the treatment of primary infection.8,5 In 1962, Pulec and Williams 5 reported that in the 20 years after the introduction of antibiotics they found only four patients with chronic abscess in the petrous apex; these were treated surgically. We are reporting the occurrence of a chronic abscess of the petrous pyramid in a child with a subtle clinical course, and the subsequent successful surgical treatment.
c
Case Report
This 5-year-old boy was well until 7 weeks before admission when he started to complain of headaches. These occurred almost every day lasting about one-half to 1 hour and were relieved by aspirin; later they also occurred 116
9 otitis media
9 petrous pyramid
at night. The headaches were described as pounding in character and localized to the left temple and behind the left ear. Two weeks after the onset of the headaches, the boy's mother noticed that he was talking out of the right side of his mouth while the left side failed to move. He later complained of earaches which occurred almost daily but did not increase in intensity. He did not complain of hearing loss or tinnitus and there was no history of infection, fever, or drainage from the ear. Examination. The patient was apprehensive and uncooperative but alert and oriented; he complained of severe pain in the left temporal region. Both tympanic membranes were clear, and there was no drainage from either ear. The mastoids were not tender and the neck was supple. The pupils were equal and reacted to light. The fundi had sharp disc margins. Extraocular movements were normal. He had a dense left peripheral facial weakness, and there was marked diminution J. Neurosurg. / Volume 44 / January, 1976
Chronic petrous pyramid abscess in hearing on the left. The palate elevated without deviation, and the tongue protruded in midline. Facial sensation including corneal sensation was normal, as was all other sensory and motor testing. The tendon reflexes were symmetrical and plantar responses were flexor bilaterally. His gait was normal without ataxia. Urinalysis and routine blood count were normal on admission to the hospital. The white count later rose to 16,400/cu mm. Spinal fluid examination showed clear, colorless fluid with a protein content of 20 rag%, and no cells. Skull x-ray films revealed that the medial aspect of the left petrous ridge was completely destroyed and the internal auditory canal could not be identified (Fig. 1). The petrous ridge on the right was normal. A bone scan using fluorine-18 showed no abnormal uptake. Audiometry showed some conduction loss on the left. The patient's temperature remained within normal range during the period of observation. He complained of dizziness and a "tickling" sound in the left ear and became progressively lethargic. On reexamination, the left tympanic membrane was gray. There was unsustained horizontal nystagmus on right lateral gaze. Plantar responses remained flexor and the neck supple. A pneumoencephalogram showed a normal ventricular system. However, air in the cerebellopontine angle cistern on the left was elevated and surrounded a mass arising from the medial petrous ridge (Fig. 2). Operation. A left suboccipital craniectomy exposed a bulging dura over the medial petrous ridge. The dura was incised and revealed an underlying abscess; this was evacuated, irrigated copiously with antibiotic solution, and the bone cavity was scraped clean. The wound was closed in layers without a drain, and healed well without evidence of meningeal reaction. Postoperative Course. Postoperatively, the boy was treated for 2 weeks with massive doses of intravenous penicillin (2.5 M units/4 hrs). The organism cultured from the abscess was pneumococcus. During his stay, the boy's facial weakness improved. Skull films including tomograms of the petrous bone and mastoid repeated 6 months after the operation showed no evidence of bone erosion. The destructive process appeared completely healed (Fig. 3). An J. Neurosurg. / Volume 44 /January, 1976
Fr~. 1. Skull film showing extensive erosion of the left petrous pyramid.
Fro. 2. Pneumoencephalogram with air in the left cerebellopontine angle surrounding a mass over the petrous pyramid.
Fro. 3. Skull film 6 months after surgery showing reossification of the left petrous bone.
audiogram 8 months after surgery showed that there was no hearing in his left ear for pure tones or speech. On reexamination 1 year after surgery the patient was asymptomatic. He was active and had returned to school. There was no tenderness over the mastoid areas, incoordination of his limbs, or ] 17
F, E. Glasauer and W. Grand gait disturbance. His hearing appeared unchanged and the facial weakness had completely recovered. Discussion
In chronic abscess of the petrous bone, the complex of Gradenigo is usually absent. 2 As a rule, pain is the first symptom, usually localized in the ear, but it may radiate into the cheek or the occiput. In some cases facial palsy precedes the pain. The onset of symptoms as a rule is 2 to 4 weeks after otitis media. Signs of mastoiditis are usually present although in chronic types of mastoiditis, these signs may be inconspicuous. In a few cases, the seventh nerve is involved and there may be vertigo and tinnitus which suggests irritation of the labyrinth? In most cases eye pain is the first symptom and is the result of irritation of the ophthalmic branch of the trigeminal nerve. Usually there is an interval of freedom from all pain of diagnostic importance ranging from 1 to 7 days. This period is dangerous since it may lead the patient and surgeon to conclude that the lesion is healing. On the contrary, in the majority of cases studied this period coincided with the invasion of the endocranium. No previous cases of chronic abscess report sixth nerve involvement. Therefore, Gradenigo's syndrome as such is not diagnostic of a petrous suppuration and, conversely, not all cases of petrous abscess produce a paralysis of the sixth nerve. According to Myerson 4 suppuration of the petrous pyramid occurs approximately once m every 300 cases of otitis media. The disease can be distinguished by its location. The
] 18
superiorly placed infection shows a break in the superior line on x-ray film or roof of the apical cavity. This indicates an extrapetrosal lesion which is really a large epidural abscess. In the inferiorly placed infections, the disease has not reached the roof of the apical cavity, but the pus has accumulated in its inferior portion. The success of combined surgical and antibiotic treatment in our case was confirmed by recalcification of the previously noted petrous bone erosion on follow-up skull films 6 months postoperatively. No recurrent infection was noted in a 2-year follow-up period. References 1. Ford FR: Diseases of the Nervous System in Infancy, Childhood and Adolescence, ed 5.
Springfield, Ill, Charles C Thomas, 1966 2. Kopetzky S J, Almour R: The suppuration of the petrous pyramid: pathology, symptomatology and surgical treatment. Ann Otol Rhinol Laryngol 40:157-177, 1931 3. Matson DD: Neurosurgery of Infancy and Childhood, ed 2. Springfield, Ill, Charles C Thomas, 1969 4. Myerson MC: Suppuration of the petrous pyramid: some views on its surgical management. Arch Ophthalmol Otol 26:42-48, 1937 5. Pulec JL, Williams HL: Chronic abscess of the petrous apex. Report of a case. Arch Otolaryngol 75:419-421, 1962
Address reprint requests to: Franz E. Glasauer, M.D., Department of Neurosurgery, E. J. Meyer Memorial Hospital, 462 Grider Street, Buffalo, New York 14215.
J. Neurosurg. / Volume 44 /January, 1976
FRANZ E. GLASAUER, M.D., AND WALTER GRAND, M.D.
Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York ~" The authors present the case of a 5-year-old boy with a chronic petrous pyramid abscess and without a history of otitis media. Treatment by posterior fossa exploration and drainage with antibiotics was successful. KEY WORDS 9 chronic abscess 9 posterior fossa
HRONIC abscess or osteomyelitis of the petrous bone as a result of direct or venous extension of acute suppuration, sinusitis, or mastoiditis is rare and has been almost unknown since the general use of antibiotics in the treatment of primary infection.8,5 In 1962, Pulec and Williams 5 reported that in the 20 years after the introduction of antibiotics they found only four patients with chronic abscess in the petrous apex; these were treated surgically. We are reporting the occurrence of a chronic abscess of the petrous pyramid in a child with a subtle clinical course, and the subsequent successful surgical treatment.
c
Case Report
This 5-year-old boy was well until 7 weeks before admission when he started to complain of headaches. These occurred almost every day lasting about one-half to 1 hour and were relieved by aspirin; later they also occurred 116
9 otitis media
9 petrous pyramid
at night. The headaches were described as pounding in character and localized to the left temple and behind the left ear. Two weeks after the onset of the headaches, the boy's mother noticed that he was talking out of the right side of his mouth while the left side failed to move. He later complained of earaches which occurred almost daily but did not increase in intensity. He did not complain of hearing loss or tinnitus and there was no history of infection, fever, or drainage from the ear. Examination. The patient was apprehensive and uncooperative but alert and oriented; he complained of severe pain in the left temporal region. Both tympanic membranes were clear, and there was no drainage from either ear. The mastoids were not tender and the neck was supple. The pupils were equal and reacted to light. The fundi had sharp disc margins. Extraocular movements were normal. He had a dense left peripheral facial weakness, and there was marked diminution J. Neurosurg. / Volume 44 / January, 1976
Chronic petrous pyramid abscess in hearing on the left. The palate elevated without deviation, and the tongue protruded in midline. Facial sensation including corneal sensation was normal, as was all other sensory and motor testing. The tendon reflexes were symmetrical and plantar responses were flexor bilaterally. His gait was normal without ataxia. Urinalysis and routine blood count were normal on admission to the hospital. The white count later rose to 16,400/cu mm. Spinal fluid examination showed clear, colorless fluid with a protein content of 20 rag%, and no cells. Skull x-ray films revealed that the medial aspect of the left petrous ridge was completely destroyed and the internal auditory canal could not be identified (Fig. 1). The petrous ridge on the right was normal. A bone scan using fluorine-18 showed no abnormal uptake. Audiometry showed some conduction loss on the left. The patient's temperature remained within normal range during the period of observation. He complained of dizziness and a "tickling" sound in the left ear and became progressively lethargic. On reexamination, the left tympanic membrane was gray. There was unsustained horizontal nystagmus on right lateral gaze. Plantar responses remained flexor and the neck supple. A pneumoencephalogram showed a normal ventricular system. However, air in the cerebellopontine angle cistern on the left was elevated and surrounded a mass arising from the medial petrous ridge (Fig. 2). Operation. A left suboccipital craniectomy exposed a bulging dura over the medial petrous ridge. The dura was incised and revealed an underlying abscess; this was evacuated, irrigated copiously with antibiotic solution, and the bone cavity was scraped clean. The wound was closed in layers without a drain, and healed well without evidence of meningeal reaction. Postoperative Course. Postoperatively, the boy was treated for 2 weeks with massive doses of intravenous penicillin (2.5 M units/4 hrs). The organism cultured from the abscess was pneumococcus. During his stay, the boy's facial weakness improved. Skull films including tomograms of the petrous bone and mastoid repeated 6 months after the operation showed no evidence of bone erosion. The destructive process appeared completely healed (Fig. 3). An J. Neurosurg. / Volume 44 /January, 1976
Fr~. 1. Skull film showing extensive erosion of the left petrous pyramid.
Fro. 2. Pneumoencephalogram with air in the left cerebellopontine angle surrounding a mass over the petrous pyramid.
Fro. 3. Skull film 6 months after surgery showing reossification of the left petrous bone.
audiogram 8 months after surgery showed that there was no hearing in his left ear for pure tones or speech. On reexamination 1 year after surgery the patient was asymptomatic. He was active and had returned to school. There was no tenderness over the mastoid areas, incoordination of his limbs, or ] 17
F, E. Glasauer and W. Grand gait disturbance. His hearing appeared unchanged and the facial weakness had completely recovered. Discussion
In chronic abscess of the petrous bone, the complex of Gradenigo is usually absent. 2 As a rule, pain is the first symptom, usually localized in the ear, but it may radiate into the cheek or the occiput. In some cases facial palsy precedes the pain. The onset of symptoms as a rule is 2 to 4 weeks after otitis media. Signs of mastoiditis are usually present although in chronic types of mastoiditis, these signs may be inconspicuous. In a few cases, the seventh nerve is involved and there may be vertigo and tinnitus which suggests irritation of the labyrinth? In most cases eye pain is the first symptom and is the result of irritation of the ophthalmic branch of the trigeminal nerve. Usually there is an interval of freedom from all pain of diagnostic importance ranging from 1 to 7 days. This period is dangerous since it may lead the patient and surgeon to conclude that the lesion is healing. On the contrary, in the majority of cases studied this period coincided with the invasion of the endocranium. No previous cases of chronic abscess report sixth nerve involvement. Therefore, Gradenigo's syndrome as such is not diagnostic of a petrous suppuration and, conversely, not all cases of petrous abscess produce a paralysis of the sixth nerve. According to Myerson 4 suppuration of the petrous pyramid occurs approximately once m every 300 cases of otitis media. The disease can be distinguished by its location. The
] 18
superiorly placed infection shows a break in the superior line on x-ray film or roof of the apical cavity. This indicates an extrapetrosal lesion which is really a large epidural abscess. In the inferiorly placed infections, the disease has not reached the roof of the apical cavity, but the pus has accumulated in its inferior portion. The success of combined surgical and antibiotic treatment in our case was confirmed by recalcification of the previously noted petrous bone erosion on follow-up skull films 6 months postoperatively. No recurrent infection was noted in a 2-year follow-up period. References 1. Ford FR: Diseases of the Nervous System in Infancy, Childhood and Adolescence, ed 5.
Springfield, Ill, Charles C Thomas, 1966 2. Kopetzky S J, Almour R: The suppuration of the petrous pyramid: pathology, symptomatology and surgical treatment. Ann Otol Rhinol Laryngol 40:157-177, 1931 3. Matson DD: Neurosurgery of Infancy and Childhood, ed 2. Springfield, Ill, Charles C Thomas, 1969 4. Myerson MC: Suppuration of the petrous pyramid: some views on its surgical management. Arch Ophthalmol Otol 26:42-48, 1937 5. Pulec JL, Williams HL: Chronic abscess of the petrous apex. Report of a case. Arch Otolaryngol 75:419-421, 1962
Address reprint requests to: Franz E. Glasauer, M.D., Department of Neurosurgery, E. J. Meyer Memorial Hospital, 462 Grider Street, Buffalo, New York 14215.
J. Neurosurg. / Volume 44 /January, 1976
