Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Skull Base, Petrous Apex, Infection Workup

  • Author: Andrea H Yeung, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 15, 2016
 

Laboratory Studies

See the list below:

  • 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.
Next

Imaging Studies

See the list below:

  • 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.
Previous
 
 
Contributor Information and Disclosures
Author

Andrea H Yeung, MD Assistant Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco

Andrea H Yeung, MD is a member of the following medical societies: Alpha Omega Alpha, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Lawrence R Lustig, MD Francis A Sooy Endowed Professor, 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, School of Medicine

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 Otological Society, North American Skull Base Society, Society for Neuroscience, Society of University Otolaryngologists-Head and Neck Surgeons, American Neurotology Society, Association for Research in Otolaryngology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gerard J Gianoli, MD Clinical Associate Professor, Departments of Otolaryngology-Head and Neck Surgery and Pediatrics, Tulane University School of Medicine; President, The Ear and Balance Institute; Board of Directors, Ponchartrain Surgery Center

Gerard J Gianoli, MD is a member of the following medical societies: American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Vesticon<br/>Received none from Vesticon, Inc. for board membership.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Acknowledgements

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.

References
  1. DeWeese D. Four unusual cases of temporal bone disease. Laryngoscope. 1958 Jun. 68(6):1028-35. [Medline].

  2. Gradenigo G. Uber circumscripte leptomeningitis mit spinalensymptomen und paralyse des n. Abducens otitischen ursprungs. Archiv f?enheilkunde. 1904. 62:255-270.

  3. Kopetzky S, Almour R. Suppuration of the petrous pyramid: symptomatology, pathology and surgical treatment. Ann Otol Rhinol Laryngol. 1931. 40:396-414.

  4. Ramadier J. Exploration de la pointe du rocher par la voie du canal carotidien. Ann d'Oto-laryngol. 1933. 4:422-444.

  5. Lempert J. Complete apicectomy (mastoidotympanoapicectomy). Arch Otolaryngol. 1937. 25:144-177.

  6. Hendershot EL, Wood JW. The middle fossa approach in the treatment of petrositis. Arch Otolaryngol. 1973 Dec. 98(6):426-7. [Medline].

  7. Profant HJ. Gradenigo's syndrome. Arch Otolaryngol. 1931. 13:347-378.

  8. Lindsay J. Suppuration in the petrous pyramid. Ann Otol Rhinol Laryngol. 1938. 47:3-36.

  9. Valles JM, Fekete R. Gradenigo syndrome: unusual consequence of otitis media. Case Rep Neurol. 2014 May. 6(2):197-201. [Medline]. [Full Text].

  10. Choi KY, Park SK. Petrositis with bilateral abducens nerve palsies complicated by acute otitis media. Clin Exp Otorhinolaryngol. 2014 Mar. 7(1):59-62. [Medline]. [Full Text].

  11. Lee DH, Kim MJ, Lee S, Choi H. Anatomical Factors Influencing Pneumatization of the Petrous Apex. Clin Exp Otorhinolaryngol. 2015 Dec. 8 (4):339-44. [Medline]. [Full Text].

  12. Montgomery W. Cystic lesion of the petrous apex: transsphenoid approach. Trans Am Otol Soc. 1977. 65:32-39.

  13. Chole RA, Donald PJ. Petrous apicitis. Clinical considerations. Ann Otol Rhinol Laryngol. 1983 Nov-Dec. 92(6 Pt 1):544-51. [Medline].

  14. Dearmin R. A logical survival approach to the tip cells of the petrous pyramid. Arch Otolaryngol. 1937. 26:321-326.

  15. Eagleton W. Localized bulbar cisterna (pontine) meningitis, facial pain, and sixth nerve palsy and their relation to caries of the petrous apex. Arch Surg. 1930. 20:386-420.

  16. Eloy JA, Bederson JB, Smouha EE. Petrous apex aspergillosis as a long-term complication of cholesterol granuloma. Laryngoscope. 2007 Jul. 117(7):1199-201. [Medline].

  17. Farrior B. The sublabyrinthine exenteration of the petrous apex. Ann Otol Rhinol Laryngol. 1942. 51:1007-1015.

  18. Hafidh MA, Keogh I, Walsh RM, et al. Otogenic intracranial complications. a 7-year retrospective review. Am J Otolaryngol. 2006 Nov-Dec. 27(6):390-5. [Medline].

  19. Holmgren G. A case of Gradenigo's syndrome. Acta Otolaryngol (Stockh). 1922. 4:491-492.

  20. 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. [Medline].

  21. Myerson M, Rubin H. Further experiences with suppuration of the petrous pyramid. Arch Otolaryngol. 1937. 26:321-326.

  22. Sears W. Otogenic paralysis of the abducens, with special mention of isolated palsy associated with irritation of the gasserian ganglion. Ann Otol Rhinol Laryngol. 1926. 35:349-422.

  23. Sethi A, Sabherwal A, Gulati A, et al. Primary tuberculous petrositis. Acta Otolaryngol. 2005 Nov. 125(11):1236-9. [Medline].

  24. Visosky AM, Isaacson B, Oghalai JS. Circumferential petrosectomy for petrous apicitis and cranial base osteomyelitis. Otol Neurotol. 2006 Oct. 27(7):1003-13. [Medline].

Previous
Next
 
Internal anatomy of the skull base, lateral view, and base of the skull.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.