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Otitis Media, Facial Pain, Diplopia
This case features a patient presenting with otitis media, facial pain, and diplopia, ultimately diagnosed with petrous apicitis.
Imaging overview:
Axial T1, axial T1 post-contrast MRI, and axial CTA of the skull base demonstrate abnormal T1 signal in the petrous apex with peripheral enhancement and opacification on CTA. Adjacent clivus involvement, retained secretions in the mesotympanum and mastoid air cells, and abnormal narrowing and enhancement of the internal carotid artery are also identified.
Clinical insight:
Petrous apicitis is an uncommon but serious complication of otitis media resulting from infection spreading to the pneumatized petrous apex. Its classic presentation is Gradenigo’s syndrome, defined by the triad of otitis media, ipsilateral facial pain from trigeminal ganglion involvement in Meckel’s cave, and diplopia from sixth cranial nerve involvement in Dorello’s canal — though not all three components are always present. Additional areas of skull base osteomyelitis may also occur and should be specifically sought on imaging. Recognizing the proximity of the trigeminal ganglion and sixth cranial nerve to the petrous apex is essential for understanding the clinical manifestations and guiding prompt treatment.
Case courtesy of Daniel E. Meltzer, MD,
Mount Sinai Hospital, NYC.