eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Skull Base

Skull Base, Petrous Apex, Infection: Workup

Author: Andrea H Yeung, MD, BS, Clinical Instructor, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco
Coauthor(s): Lawrence R Lustig, MD, Professor and Francis A Sooy Chair, Department of Otolaryngology, Division Chief of Otology, Neurotology, and Skull Base Surgery, Director of UCSF Cochlear Implant Program, Co-Director of UCSF Center for Balance and Falls, University of California San Francisco
Contributor Information and Disclosures

Updated: Nov 6, 2008

Workup

Laboratory Studies

  • In cases of radiographically documented petrous apicitis, culturing middle ear effusions is important to help discern the microbiologic etiology and institute appropriate antibiotic therapy. This may be accomplished via paracentesis through an intact drum or culture of any purulent otorrhea.
  • Additional important lab studies include a CBC count, electrolyte tests (eg, sodium, potassium, chloride), and a blood glucose determination.

Imaging Studies

  • CT has replaced plain-film tomography as the standard diagnostic study for assessing skull base processes.
    • Temporal bone features diagnostic of petrous apicitis on CT scan include opacification of the mastoid air cell system, including the petrous apex; enhancement of the cavernous sinus; and bony erosion within the petrous apex. With contrast, cavernous sinus enhancement may also occur.
    • Acute petrositis may appear as an expanding lesion with irregular margins. In contrast, chronic petrous apicitis may demonstrate hypopneumatization and sclerosis.
  • MRI provides additional important information unavailable with CT.
    • In acute apicitis, a high-resolution MRI with gadolinium through the temporal bone demonstrates a low-intensity (ie, hypointense) signal on T1-weighted images, shows a high-intensity (ie, hyperintense) signal on T2-weighted images, and has ring enhancement with gadolinium dye.
    • In chronic apicitis, findings resemble chronic mastoiditis, showing a hyperintense signal on T2-weighted images. Some enhancement may occur with gadolinium, although not to the same degree as in acute apicitis.
    • These findings are key to diagnosis and help distinguish petrous apicitis from other lesions of the petrous apex, such as cholesterol granuloma (hyperintense on T1- and T2-weighted images, no gadolinium enhancement), cholesteatoma (hypointense on T1-weighted images, hyperintense on T2-weighted images, no gadolinium enhancement), and neoplasia (hypointense on T1-weighted images, hyperintense on T2-weighted images, and gadolinium enhancement).
  • Single-photon emission computed tomography and nuclear imaging studies
    • Single-photon emission computed tomography (SPECT) may be useful when CT or MRI is nondiagnostic. SPECT also can assist in identifying subtle petrous apex inflammation.
    • SPECT findings in petrous apicitis include focal uptake of signal within the affected petrous apex.

More on Skull Base, Petrous Apex, Infection

Overview: Skull Base, Petrous Apex, Infection
Workup: Skull Base, Petrous Apex, Infection
Treatment: Skull Base, Petrous Apex, Infection
Follow-up: Skull Base, Petrous Apex, Infection
References
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References

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Further Reading

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Keywords

petrous apex, petrous apex infection, skull base infection, petrous apicitis, Gradenigo syndrome, Gradenigo's syndrome, petrositis, temporal bone

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Contributor Information and Disclosures

Author

Andrea H Yeung, MD, BS, Clinical Instructor, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco
Andrea H Yeung, MD, BS is a member of the following medical societies: Alpha Omega Alpha and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Lawrence R Lustig, MD, Professor and Francis A Sooy Chair, Department of Otolaryngology, Division Chief of Otology, Neurotology, and Skull Base Surgery, Director of UCSF Cochlear Implant Program, Co-Director of UCSF Center for Balance and Falls, University of California San Francisco
Lawrence R Lustig, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American College of Surgeons, American Neurotology Society, American Otological Society, Association for Research in Otolaryngology, North American Skull Base Society, Society for Neuroscience, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Douglas D Backous, MD, Director of Listen for Life Center, Department of Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center
Douglas D Backous, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Association for Research in Otolaryngology, North American Skull Base Society, Society for Neuroscience, and Washington State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gerard J Gianoli, MD, Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center
Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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