Patients affected by a petrositis typically present with Gradenigo's syndrome, a triad of symptoms involving an abducens nerve palsy, suppurative otitis media and facial pain that follows the distribution of the trigeminal nerve. Nevertheless, not every patient diagnosed with petrositis tends to exhibit all three symptoms upon diagnosis [1] [2] [3]. In cases where petrositis occurs secondary to an otitis media and mastoiditis, fever, otorrhea that persists for more than three weeks, erythema in the region of the mastoid and ipsilateral pain tend to be the symptoms that patients present with, alongside Gradenigo's syndrome [4]. Additional symptoms that may accompany the aforementioned presentation include:

• Facial paralysis, due to extension of the infection to the facial nerve
• Vertigo
• Involvement of the vestibulocochlear, glossopharyngeal or vagus nerve. Symptoms that are elicited may be those of nasal speech, bovine cough or pseudobulbar palsy; the latter occurs in cases where the petrous apex of the temporal bone is bilaterally affected.
• Hearing impairment due to extension of the infection to the labyrinth [5]

Petrositis, if left undiagnosed or untreated, can affect various structures in the vicinity of the temporal bone. If such complications occur, symptoms may vary and include thrombosis of the sigmoid, dural venous or cavernous sinus, thrombotic events of the jugular vein, an epidural or cerebral abscess, a subdural empyema, frank meningitis and loss of orientation or coma.

• Increased Susceptibility to Infections

  U&E and blood glucose - may give clues as to underlying causes of increased susceptibility to infection - eg, diabetes, chronic kidney disease or other metabolic disturbance. [patient.info]

• Nasal Speech

  Symptoms that are elicited may be those of nasal speech, bovine cough or pseudobulbar palsy; the latter occurs in cases where the petrous apex of the temporal bone is bilaterally affected. [symptoma.com]

  Rarely, there may be symptoms or signs of dysfunction due to palsies of the Xth cranial nerve (nasal speech and bovine cough) or IXth cranial nerve (pseudobulbar palsy but only if there is bilateral disease). [patient.info]

Diagnosing petrositis initially requires a detailed clinical examination and medical history. Symptoms obtained from the medical history that raises suspicion towards petrositis includes the following:

• Otorrhea, abducens nerve palsy, pain along the distribution of the trigeminal nerve (Gradenigo's syndrome)
• Fever
• Otalgia
• Erythema and pain in the region of the mastoid
• Facial paralysis
• Vertigo
• Pseudobulbar palsy, bovine cough or nasal speech

With regard to the laboratory examinations that can aid towards the diagnosis of petrositis, a complete blood count and biochemical profile are expected to show leukocytosis, an augmented erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP); other pathological findings such as an increased blood glucose or abnormal urea and creatinine levels, can direct the physician towards an underlying condition that predisposes the patient to a petrositis. A sample from the ear suppuration can also be cultured, in order to isolate the pathogen responsible for the infection. The sample can be collected via myringotomy or direct drainage in cases of eardrum perforation.

A computerized tomography (CT) or magnetic resonance imaging (MRI) scan, alongside a single-photon emission computed tomography scan (SPECT) are also able to depict the petrous apex of the temporal bone and diagnose an infection, with the MRI being the imaging modality of choice regarding the differential diagnosis of an infection and a malignant tumor [6] [7]. Finally, a radioisotope bone scan can also be used in the diagnostic approach [7].

Treatment of petrotitis: surgery is risky and drug therapy is feasible The difficulty in the treatment of this case was the options between surgery and conservative treatment, The drug therapy has been adjusted for several times. [bmcinfectdis.biomedcentral.com]

Conservative treatment could be a good choice. [ncbi.nlm.nih.gov]

Diagnosis and treatment. ( 4651111 ) 1972 19 Tomography in the diagnosis of petrositis. ( 4659481 ) 1972 20 Pathology of petrositis. ( 5722893 ) Allam A.F....Schuknecht H.F. 1968 21 Apical petrositis. [malacards.org]

The prognosis remains poor especially in immunocompromised patients despite appropriate treatment. [ncbi.nlm.nih.gov]

Prognosis Formerly, the prognosis was very poor with death a common occurrence. [patient.info]

[…] of Petrositis Initially the prognosis was very dissatisfying with death a common occurrence. [altiusdirectory.com]

Record : found Abstract : found Article : not found Cause and prognosis of nontraumatic sixth nerve palsies in young adults. To review the causes and prognosis of sixth nerve palsies in patients who are 20 to 50 years of age. [scienceopen.com]

Treatment and prognosis In many instances treatment with appropriate intravenous antibiotics suffices. In more severe cases surgical drainage may be required 4. [radiopaedia.org]

Etiologic aspects involved in the process are discussed and the name non-specific necrotizing petrositis is suggested to individualize this rare form of otitis which, with morbidity, leads to severe complications such as facial paralysis and deafness. [ncbi.nlm.nih.gov]

This case demonstrated that (1) myofascial pain and dysfunction syndrome that does not respond to conventional treatments may suggest an unusual etiology and warrant further medical investigations and a detailed medical history and that (2) petrositis [archive-ouverte.unige.ch]

The most common etiology of this syndrome is an infection. [2] We reported a case that differs from these published reports: An NPC the etiology of Gradenigo's syndrome; the presence of recurrent symptoms of the syndrome persisted in a patient. > Case [cancerjournal.net]

An awareness of its existence and appropriate levels of suspicion of the condition are necessary to prevent severe damage or death in those affected.[2, 3] Epidemiology There are no reliable recent figures. [patient.info]

Epidemiology Frequency Petrous apicitis was commonly encountered before the introduction of antibiotics. It now appears quite rarely. [emedicine.medscape.com]

Epidemiology of candida bloodstream infections in a tertiary care institute in India. Indian J Med Microbiol. 2009;27(2):171–2. Article CAS PubMed Google Scholar Pristov KE, Ghannoum MA. Resistance of Candida to azoles and echinocandins worldwide. [bmcinfectdis.biomedcentral.com]

Pathophysiology of urinary tract obstruction. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Elsevier; 2016:chap 48. Nakada SY, Best SL. Management of urinary tract obstruction. [mclaren.org]

Pathophysiology Because of the extensive pneumatization and presence of rich bone marrow within the petrous apex, it is susceptible to infection or inflammation, typically in combination with mastoiditis. [emedicine.medscape.com]

[…] in cases of acute otitis media ( where they are felt to be indicated) may help to prevent chronic presentations due to partially treated mastoiditis. [patient.info]

/Avoidable - 0% Emergent - ED Care Needed - Not Preventable/Avoidable - 0% Primary diagnosis of injury 0% Primary diagnosis of mental health problems 0% Primary diagnosis of substance abuse 0% Primary diagnosis of Alcohol 0% Unclassified 100% Health Topic [codelay.com]

Prevention There is no known prevention for normal knock knees. References Demay MB, Krane SM. Disorders of mineralization. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. [mclaren.org]

In either of these cases, some surgeons advocate placing a drain, such as silastic draped from the infected site into the mastoid or hypotympanum, to maintain the patency of the drainage pathway and prevent recurrence of the infection. [emedicine.medscape.com]

Prevention Using right antibiotics for recommended time period in cases of severe otitis media, where they are felt to be uses, may assist to ward off chronic manifestations because of partially treated mastoiditis. [altiusdirectory.com]

1. Mafee MF, Singleton EL, Valvassori GE, et al. Acute otomastoiditis and its complications: role of CT. Radiology. 1985;155 (2): 391-7.
2. Head and neck imaging. Peter MS, Hugh DC, St Louis (eds). Mosby-Year Book, 2003.
3. Chole RA, Sudhoff HH. Chronic otitis media, mastoiditis, and petrositis. In: Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins KT, et al., eds. Cummings otolaryngology head and neck surgery. 5th ed. Philadelphia, PA: Mosby; c2010. pp. 1963–1978.
4. Vazquez E, Castellote A, Piqueras J, et al. Imaging of complications of acute mastoiditis in children. Radiographics. 23 (2): 359-72.
5. Lutter SA, Kerschner JE, Chusid MJ. Gradenigo syndrome: a rare but serious complication of otitis media. Pediatr Emerg Care. 2005 Jun;21(6):384–386.
6. Lee YH, Lee NJ, Kim JH, et al. CT, MRI and gallium SPECT in the diagnosis and treatment of petrous apicitis presenting as multiple cranial neuropathies. Br J Radiol. 2005 Oct;78(934):948-51
7. Pedroso JL, de Aquino CC, Abrahao A, et al. Gradenigo's Syndrome: Beyond the Classical Triad of Diplopia, Facial Pain and Otorrhea. Case Rep Neurol. 2011 Feb 15;3(1):45-7. doi: 10.1159/000324179.