petrous apicitis is an extension of infection from the mastoid air cell tract into a pneumatized anterior or posterior petrous apex . the petrous apex may be pneumatic , marrow filled , or sclerotic , and it has been estimated that 30% of posterior petrous apices are pneumatized . prior to the introduction of widely available antibiotics , apical petrositis was a frequently fatal complication of otitis media . unrecognized and under - treated petrositis can lead to clinically important complications including meningitis , extradural and intracranial abscesses , cranial nerve palsies , venous sinus thrombosis , subdural empyema , labyrinthitis and death . with only the thin dura mater separating the trigeminal ganglion and the sixth cranial nerve from the bony petrous apex , they are vulnerable to inflammatory processes in that region , resulting in deep facial pain , lateral rectus paralysis , and diplopia . in 1904 , gradenigo described the triad of retroorbital pain , the sixth cranial nerve paralysis , and otorrhea , since known as gradenigo syndrome . only a few patients with petrous apicitis exhibited the full triad these days . a short review of english literature showed only 13 cases of complete gradenigo syndrome in children during otitis media since 1980 . three cases were successfully treated surgically , an 8-year - old boy with both petrous apicitis and ipsilateral abducens nerve palsy , 29-year - old male with petrositis and the abducens palsy , and a patient with full triad of symptoms of gradenigo syndrome . one case showed improvement without surgery , an 8-year - old female with cavernous sinus thrombophlebitis and abducence nerve palsy secondary to petrositis , who had complete resolution of her symptoms after antibiotics , steroids and ventilation tube insertion . we presented a case of petrositis after acute otitis media ( aom ) with both abducence nerve palsies , which was managed medically without any steroid or surgical intervention . 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 . 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 ( fig . 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 . laboratory tests showed a white blood cell count of 6 , 290 mm 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 ( fig . temporal bone ct showed soft tissue densities at left mastoid , middle ear , and well - developed petrous apex cells ( fig . 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 . 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 ( fig . 1b ) , 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 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 / the strabismus returned to preadmission state , and the patient was finally discharged ( fig . 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 ( fig . petrositis is a rare complication of otitis media . in minottis 's research of 100 children admitted to children 's hospital of pittsburgh between 1980 and 1995 with an intratemporal complication of aom , four patients presented with acute petrositis . patients exhibiting the full triad of gradenigo syndrome , retroorbital pain , the sixth cranial nerve paralysis , and otorrhea , are very rare . a review of the english literature for gradenigo syndrome or petrous apicitis revealed only 48 publications concerning this entity , most in the otolaryngology literature . in korea , only 4 case reports of petrositis with abducens nerve palsy have been found on recent reviews of the korean - language literatures . most cases of petrous apicitis are considered to occur in patients with well - developed air cell systems extending into the petrous apex . the time interval between the onset of the otitis and the manifestation of cranial nerve dysfunction varies between one week and two to three months . this is not surprising , since the petrous apex is the summit of the pyramid - shaped os petrosum , of which the middle ear and the mastoid form the base . the inflammatory process spreads from the base to the top of the pyramid , extending along the strings of pneumatized cells from the mastoid towards the petrous apex . in addition to the triad symptoms of gradenigo syndrome , petrous apicitis may have variable presentations . other symptoms include ipsilateral facial paralysis due to involvement of the 7th cranial nerve , deficits of cranial nerves viii , ix , and x , vertigo , and sensorineural hearing loss as a result of labyrinthine involvement of the inner ear . a patient , who had three recurrent episodes of unilateral sixth nerve palsy that occurred after a viral upper respiratory tract infection , has been described . each time , the patient was managed conservatively and had complete return of the sixth cranial nerve function within two weeks . no reported case of bilateral abducens nerve palsies after aom has been found , but bilateral abducens nerve palsies occurring after meningitis , sphenositis , etc . but the fact that the cavernous sinus also encases contralateral abducens nerve , optic nerve etc . chole and donald , stated that aggressive surgical drainage is indicated when the diagnosis of petrous apicitis is made , and watkyn - thomas   reported that petrositis is curable by adequate mastoid operation . hendershot et al .   presented middle fossa approach for the the treatment of petrous apicitis . but recent reports advocate conservative therapy with high - dose broad - spectrum antibiotics and less aggressive surgical procedures , and actually five cases among 48 reviewed english literatures were treated without surgery . insisted on the possibility of a conservative management of gradenigo syndrome in children , when diagnosis is performed before intracranial complications , and reported a case of a 6-year - old boy with gradenigo syndrome managed medically with a positive outcome . the patient had been treated at first by oral antibiotics ( amoxicillin at a dose of 50 mg / kg per day ) for a right otitis media , but right diplopia occurred and intravenous antibiotics were started . he received ceftriaxone ( 50 mg / kg per day ) , metronidazole ( 40 mg / kg per day ) for 33 days and amikacin ( 5 mg / kg per day ) for 3 days , plus acetyl salycilic acid and an intravenous corticotherapy ( methylprednisolone ) . discharge medication was oral amoxicillin ( 100 mg / kg per day ) and clavulanate , and complete recovery of the abducens palsy was noted . minotti and kountakis   reported a case of petrositis with abducens nerve palsy managed successfully without surgical intervention , a 47-year - old woman successfully treated with intravenous antibiotics and tympanostomy tube placement . and finkelstein et al . also reported a 12-year - old boy with gradenigo syndrome successfully treated with intravenous antibiotics and tube placement . 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 , and intravenous dexamethasone ( 10 mg / day ) for 2 days , and 2 weeks of oral amoxicillin ( 40 mg / kg per day ) and clavulanic acid ( 10 mg / kg per day ) for discharge medication . one case was treated with 4 weeks of intravenous metronidazole , 6 weeks of intravenous ceftriaxone , and oral ciprofloxacin , followed by 6 weeks of ciprofloxacin and clindamycin . the other case used intravenous ceftriaxone , amoxicillin - clavulanic acid and metronidazole for 6 weeks , and oral amoxicillin - clavulanic acid and metronidazole for further 6 weeks . in 4 reported cases of korean - language literature , 3 cases were treated surgically , and only one case was cured with conservative treatment . a 8-year - old girl with abducens nerve palsy secondary to petrositis recoverd completetly with ventilation tube insertion , intravenous cefotaxime , ampicillin and oral steoid ( prednisolone , 1 mg / kg / day ) . our case showed a good example of conservative treatment ; adequate diagnosis by using imaging studies , and close observation with antibiotics and drainage through ventilation tube , before occurrence of intracranial complications . especially in children with pneumatized petrous bones , prompt treatment of otitis media however , when the conservative therapy fails or chronic ear disease is present , surgical intervention is indicated to ensure adequate drainage of the mastoid and petrous bone .
petrous apicitis is a rare but fatal complication of otitis media . 
 an infection within the middle ear can extend within the temporal bone into the air cells of the petrous apex . with only the thin dura mater separating the trigeminal ganglion and the 6th cranial nerve from the bony petrous apex , they are vulnerable to inflammatory processes , resulting in deep facial pain , lateral rectus muscle paralysis , and diplopia . in 1904 , 
 gradenigo described a triad of symptoms related to petrous apicitis , including acute suppurative otitis media , deep facial pain resulting from trigeminal involvement , and abducens nerve palsy . 
 it has traditionally been treated with surgery , but recent advances in imaging , with improved antibiotic treatment , allow conservative management . in this case report , we describe a clinical and neuroradiological evolution of a child with a petrous apicitis after acute otitis media , which was managed medically with a positive outcome .