06 February 2024
: Case report 
Fusobacterium necrophorum an Underrecognized Cause of Petrous Apicitis Presenting with Gradenigo Syndrome: A Case Report
Rare disease
Zaid Ibrahim
1ABCDEF*, Shivani Fox-Lewis2E, Jason A. Correia13AE
DOI: 10.12659/AJCR.942652
Am J Case Rep 2024; 25:e942652
Table 1. A summary of the literature reviewed.
| First author | Year | PA cases reported | GS | OM | Age | Sex | Microbiology |
|---|---|---|---|---|---|---|---|
| Adams []30 | 1938 | 1 | No | Yes | 22 | F | – |
| Bridgewater []31 | 1944 | 1 | Yes | Yes | 9 | F | – |
| Ogilvie []32 | 1945 | 2 | 1031 | –– | |||
| Weille []74 | 1947 | 1 | No | Yes | 12 | M | , non-hemolytic Streptococcus, gram-negative colon bacilli, |
| Horowitz []33 | 1948 | 2 | 1430 | –– | |||
| Nako []34 | 1949 | 1 | No | Yes | 24 | M | – |
| Adams []35 | 1950 | 1 | No | Yes | 6 | M | – |
| Bradburn []75 | 1953 | 1 | No | Yes | 4 | F | , , |
| Eby []76 | 1961 | 3 | 214438 | ||||
| Gillespie []36 | 1962 | 1 | Yes | – | – | – | – |
| Nicol []37 | 1964 | 1 | No | Yes | 42 | M | – |
| Hiranandani []77 | 1967 | 1 | Yes | Yes | 30 | M | |
| Hendershot []78 | 1976 | 4 | Nil | 16192617 | |||
| Kohut []79 | 1979 | 1 | No | No –OE | 76 | M | sp. |
| Chole []80 | 1983 | 8 | Nil | 7657184646736523 | |||
| Stamm []81 | 1984 | 3 | Nil | 232 | |||
| Kearns []82 | 1985 | 1 | No | Yes | 21 | M | , , Alpha hemolytic Streptococci, sp. |
| Hilding []38 | 1987 | 1 | No | Yes | 2 mo | M | – |
| Horn []83 | 1996 | 1 | Yes | Yes | 10 | F | Viridans streptococci |
| Murakami []39 | 1996 | 1 | Yes | Yes | 8 | F | – |
| Goldstein []84 | 1998 | 4 | Nil | Mean age=7.4 | – | ||
| Minotti []85 | 1999 | 2 | 4736 | ||||
| Fitzgerald []86 | 2001 | 1 | No | Yes | 83 | M | |
| Somers []40 | 2001 | 1 | No | Yes | 9 | F | – |
| Price []41 | 2002 | 1 | No | Yes | 7 | F | – |
| Jagadeesan []42 | 2002 | 1 | Yes | Yes | 4 | F | – |
| Piron []10 | 2003 | 1 | Yes | Yes | 5 | F | |
| Park []43 | 2003 | 1 | Yes | Yes | 8 | F | – |
| Finkelstein []87 | 2003 | 1 | Yes | Yes | 12 | M | |
| Trimis []88 | 2003 | 1 | No | Yes | 12 | F | , Enterococci, Proteus, |
| Crossland []89 | 2005 | 1 | No | Yes | 49 | F | |
| Lee []90 | 2005 | 1 | No | No | 62 | M | |
| Espay []44 | 2005 | 1 | No | No | 83 | F | – |
| Sethi []91 | 2005 | 1 | Yes | Yes | 11 | F | |
| Koral []45 | 2006 | 1 | No | Yes | 8 | M | – |
| Visosky []92 | 2006 | 4 | 8146684 | ||||
| Sethi []93 | 2006 | 1 | No | Yes | 16 | M | Ear discharge stained positive for acid-fast bacilli |
| Hafidh [] (NB: description of individual patients not provided)46 | 2006 | 3 | – | – | – | – | |
| Cundiff []14 | 2006 | 1 | No | Yes | 16 | F | |
| Zanation [] (NB: description of individual patients not provided)47 | 2009 | 4 | – | – | – | – | – |
| Isaacson [] (NB: description of individual patients not provided)94 | 2010 | 7 | – | – | – | – | |
| Rossor []48 | 2011 | 1 | Yes | Yes | 11 | F | – |
| Loreten []49 | 2011 | 1 | No | – | 86 | M | – |
| Pollock [] (NB: description of individual patients not provided)95 | 2011 | 7 | 7 | 7 | – | M=5 F=2 | |
| Kong []50 | 2011 | 1 | Yes | Yes | 10 | M | – |
| Dumas []96 | 2012 | 1 | No | Yes | 65 | M | |
| Jacobsen []3 | 2012 | 1 | Yes | Yes | 3 | M | , |
| Colpaert []97 | 2013 | 1 | Yes | Yes | 12 | F | Viridans streptococci |
| Bhatt []98 | 2013 | 1 | No | Yes | 72 | M | sp. |
| Lammers []51 | 2013 | 1 | No | Yes | 5 | M | – |
| Heshin-Bekenstein []13 | 2013 | 2 | 35 | ||||
| Chen []99 | 2014 | 4 | 64335845 | ||||
| Choi []52 | 2014 | 1 | Yes | Yes | 8 | F | – |
| Plodpai []53 | 2014 | 1 | Yes | Yes | 63 | M | – |
| Valles []100 | 2014 | 1 | Yes | Yes | 36 | F | |
| Jensen []101 | 2016 | 4 | 5467013 | ||||
| Janjua []102 | 2016 | 1 | No | Yes | 10 | F | |
| Do Vale []103 | 2016 | 1 | No | Yes | 67 | M | |
| Karunakaran []54 | 2016 | 1 | No | Yes | 13 | M | – |
| Kazemi []55 | 2017 | 1 | Yes | Yes | 33 | M | – |
| Jensen []56 | 2017 | 1 | Yes | Yes | 9 | F | – |
| Vitale []104 | 2017 | 1 | Yes | Yes | 8 | F | |
| Dorner []105 | 2017 | 1 | Yes | Yes | 5 | M | , |
| Taklalsingh []106 | 2017 | 1 | Yes | Yes | 58 | M | |
| Ghani []57 | 2017 | 1 | Yes | Yes | 7 | M | – |
| Solms []58 | 2017 | 1 | Yes | Yes | 10 | M | – |
| Shapiro []107 | 2017 | 1 | Yes | Yes | 11 | F | Group A streptococci |
| Gadre [] (NB: description of individual patients not provided)2 | 2017 | 44 | 6 (13.6%) | 27 (54.5%) | Range: 8–76Mean=39.2 | M=23F=21 | |
| Brunet-Garcia []59 | 2018 | 1 | Yes | Yes | 41 | M | – |
| Al-juboori []60 | 2018 | 1 | Yes | Yes | 61 | M | – |
| Bozan []108 | 2018 | 1 | Yes | Yes | 9 | F | Coagulase-negative staphylococcus |
| Özkaçmaz []61 | 2019 | 1 | Yes | Yes | 14 | F | – |
| Rossi []109 | 2019 | 1 | Yes | Yes | 4 | F | Coagulase-negative staphylococcus |
| Athapathu []62 | 2019 | 1 | Yes | Yes | 6 | M | – |
| Mancini []63 | 2019 | 1 | No | Yes | 65 | M | – |
| Brambilla []64 | 2019 | 1 | Yes | Yes | 8 | – | – |
| Savasta []20 | 2019 | 1 | Yes | Yes | 11 | M | – |
| McLaren []17 | 2020 | 1 | Yes | Yes | 5 | F | – |
| Patel []110 | 2020 | 2 | 4946 | ||||
| Hodges []111 | 2020 | 1 | Yes | Yes | 24 | M | |
| Demir []65 | 2020 | 1 | Yes | Yes | 7 | M | – |
| Chandran []112 | 2020 | 2 | 5423 | ||||
| Guimaraes []113 | 2021 | 1 | Yes | Yes | 63 | F | , , , , and |
| Isaac []114 | 2021 | 1 | No | Yes | 48 | M | , , |
| Bergsma []15 | 2021 | 1 | No | Yes | 10 | M | |
| Chowdhary []66 | 2021 | 1 | No | No | 32 | M | – |
| Sattarova []115 | 2021 | 1 | Yes | Yes | 65 | M | , Coagulase-negative staphylococcus, Corynebacterium |
| Malic []67 | 2021 | 1 | Yes | Yes | 5 | F | – |
| Liu []68 | 2021 | 1 | Yes | Yes | 35 | F | – |
| Quesada []116 | 2021 | 1 | Yes | Yes | 14 | F | Group A Streptococcus |
| Bonavia []117 | 2022 | 1 | Yes | Yes | 14 | F | Group A Streptococcus |
| Bano []69 | 2022 | 1 | No | No | 55 | M | – |
| Jin []118 | 2022 | 1 | Yes | Yes | 78 | M | Candida |
| Chan []119 | 2023 | 1 | Yes | Yes | 5 | M | |
| Kehayov []120 | 2023 | 1 | No | Yes | 30 | M | |
| Nassrallah []70 | 2023 | 1 | No | No | 32 | M | SARS-CoV-2 |
| Saldanha []121 | 2023 | 1 | No | Yes | 6 | M | |
| PA – petrous apicitis; GS – Gradenigo syndrome; OM – otitis media; OE – otitis externa; CN – cranial nerve; V1 – ophthalmic division of trigeminal nerve; Mo – months; ICA – internal carotid artery; CSF – cerebrospinal fluid; CPA – cerebellopontine angle; TMJ – temporomandibular joint; IV – intravenous; IM – intramuscular. | |||||||
| First author | Polymicrobial infection | Complications/associated findings | Antibiotics | Other treatments | Outcome | ||
| Adams []30 | – | Facial nerve palsy, mastoiditis, meningitis, cerebellar abscess | – | Mastoidectomy, followed by craniotomy with unsuccessful attempt to drain abscess | Death | ||
| Bridgewater []31 | – | Abducens nerve palsy, mastoiditis, extradural abscess | Sulphonamides | Mastoidectomy and petrous apex debridement | – | ||
| Ogilvie []32 | – | ||||||
| Weille []74 | Yes | Facial nerve palsy, mastoiditis, meningitis, superior petrosal and cavernous sinus thrombosis with proptosis | IM and intrathecal penicillin | Mastoidectomy and petrous apex debridement, IV heparin switched to dicumarol | Full recovery | ||
| Horowitz []33 | – | ||||||
| Nako []34 | – | Meningitis | Penicillin | First antrotomy, deteriorated then underwent mastoidectomy | Full recovery | ||
| Adams []35 | – | Mastoiditis | – | Mastoidectomy, followed by surgical re-exploration due to persistent mastoid discharge | Full recovery | ||
| Bradburn []75 | Yes | Facial nerve palsy (facial nerve noted to be destroyed at the time of surgery), mastoiditis | Penicillin, streptomycin, 4-aminosalicylic acid, chloramphenicol | Mastoidectomy, followed by surgical re- exploration and removal of lateral sinus thrombus as clinically deteriorated | Persistent facial nerve palsy, discharged against medical advice and lost to follow-up | ||
| Eby []76 | – | ||||||
| Gillespie []36 | – | – | – | – | – | ||
| Nicol []37 | – | Hearing loss, diplopia, reduced sensation within V1 distribution of trigeminal nerve | Penicillin, streptomycin | Craniotomy, petrous apex not debrided | Persistent hearing loss | ||
| Hiranandani []77 | – | Abducens nerve palsy, mastoiditis, post and preauricular abscesses | Initially tetracycline and penicillin- streptomycin injections, switched to “anti- tubercular drugs for 3 months” | Incision and drainage of abscesses, followed by mastoidectomy | – | ||
| Hendershot []78 | – | ||||||
| Kohut []79 | – | Facial nerve palsy, mastoiditis, meningitis, temporal lobe abscess | “Ear drops and antibiotics” | Mastoidectomy, craniotomy and temporal lobe abscess excision | Death | ||
| Chole []80 | – | ||||||
| Stamm []81 | 3. Yes | – | |||||
| Kearns []82 | Yes | Facial nerve palsy, hearing loss, preauricular abscess, petrous apex abscess | Isoniazid, rifampicin, pyridoxine | Mastoidectomy, middle cranial fossa craniotomy and abscess drainage | Full recovery | ||
| Hilding []38 | – | Abducens nerve palsy | Penicillin V, IV cefuroxime, 2-weeks of cefaclor after surgery | Mastoidectomy | Full recovery | ||
| Horn []83 | – | Abducens nerve palsy, subtemporal abscess | Amoxicillin, IV ceftriaxone for 6 weeks | Craniotomy and abscess drainage with petrous apex debridement | Full recovery | ||
| Murakami []39 | – | Abducens nerve palsy | Piperacillin and cefuzonam | Myringotomy | Full recovery | ||
| Goldstein []84 | – | Complications for individual patients not provided Summary of complications: – Mastoiditis ×3 – Hydrocephalus and sigmoid sinus thrombosis ×2 – Extradural abscess ×1 | “all treated with broad spectrum intravenous antibiotics” “ticarcillin disodium and clavulanate potassium was used in 2 patients” | Treatments for individual patients not provided Summary of interventions: – Myringotomy and ventilation tube placement with mastoid surgery performed for all 4 patients – Drainage of extradural abscess for 1 patient | |||
| Minotti []85 | – | ||||||
| Fitzgerald []86 | – | Facial nerve palsy, hearing loss, mastoiditis, nasopharyngeal abscess | IV moxalactam during first admission, IV tobramycin and ticarcillin | Mastoidectomy, drainage of nasopharyngeal abscess | Full recovery | ||
| Somers []40 | – | Mastoiditis, chronic infection with pericarotid extension into the neck | – | Mastoidectomy and petrous apex debridement, cervical abscess drained and washed with rifampicin solution | Hearing loss | ||
| Price []41 | – | Abducens nerve palsy, petrous apex abscess | IV amoxicillin and clavulanic acid with vancomycin, discharged with 6 weeks of oral amoxicillin and clindamycin | Myringotomy and mastoidectomy | Full recovery | ||
| Jagadeesan []42 | – | Meningitis | – | Temporal burr hole | Lost to follow-up | ||
| Piron []10 | – | Abducens nerve palsy, mastoiditis | IV ceftriaxone and metronidazole, discharged on oral amoxicillin and clavulanic acid for 1 week | Myringotomy, followed by mastoidectomy and insertion of ventilation tube | Full recovery | ||
| Park []43 | – | Abducens nerve palsy, mastoiditis, cavernous sinus thrombosis with narrowing of cavernous ICA | IV cefotaxime and ampicillin | Myringotomy and ventilation tube insertion | Full recovery | ||
| Finkelstein []87 | – | Abducens nerve palsy, mastoiditis | IV ceftriaxone, metronidazole and vancomycin, metronidazole discontinued after 7 days, discharged on 2 weeks of oral amoxicillin and clavulanic acid | Ventilation tube insertion | Full recovery | ||
| Trimis []88 | Yes | Cerebellar abscess | IV imipenem, ciprofloxacin and gentamicin, discharged on 6 weeks of oral ciprofloxacin | Petrous apex debridement (subtotal petrosectomy), deteriorated 1-week later, imaging showed development of cerebellar abscess, underwent posterior fossa craniotomy for abscess drainage | Full recovery | ||
| Crossland []89 | – | Abducens, facial, glossopharyngeal and hypoglossal nerve palsies, hearing loss, mastoiditis, mycotic aneurysm of petrous ICA | Oral ciprofloxacin, “Intravenous antibiotics” | Mastoidectomy, 6 months later underwent balloon occlusion of right ICA, deteriorated and required petrous apex debridement (total petrosectomy) | Permanent total vocal cord palsy | ||
| Lee []90 | – | Reduced facial sensation, vagus nerve palsy, mastoiditis | “Intravenous and oral antibiotics for 3 months” | Mastoidectomy | “Most of his symptoms had completely resolved after treatment” | ||
| Espay []44 | – | Ramsey-Hunt syndrome, facial, vagus and hypoglossal nerve palsies, hearing loss | “10-day course of acyclovir, 800 mg, 5 times daily” | – | Persistent cranial nerve deficits | ||
| Sethi []91 | – | Abducens nerve palsy, hearing loss, mastoiditis | Isoniazid, rifampicin, pyrazinamide and ethambutol | Mastoidectomy | Full recovery | ||
| Koral []45 | – | Abducens and facial nerve palsies, hearing loss, mastoiditis | IV oxacillin and ceftriaxone for 7 days, followed by a 3 week course of oral amoxicillin and clavulanic acid | Mastoidectomy and petrous apex debridement (infralabyrinthine approach), insertion of ventilation tube | Full recovery | ||
| Visosky []92 | 4. Yes | ||||||
| Sethi []93 | – | Facial nerve palsy, hearing loss | Initial treatment with parenteral penicillin, gentamicin and metronidazole, switched to isoniazid, rifampicin, ethambutol and pyrazinamide | – | Full recovery | ||
| Hafidh [] (NB: description of individual patients not provided)46 | – | “All patients received broad- spectrum IV antibiotics” | – | – | |||
| Cundiff []14 | – | Abducens and hypoglossal nerve palsies, hearing loss, Horner syndrome, meningitis, bilateral mastoiditis and PA, narrowing of cavernous, clinoid, ophthalmic and communicating segments of ICA, possible ICA thrombosis | IV ceftazidime, levofloxacin and clindamycin, topical ciprofloxacin | Initially myringotomy, followed by left mastoidectomy and petrous apex debridement (petrosectomy), post-operative imaging showed development of right sided mastoiditis and PA, therefore underwent right mastoidectomy and petrous apex debridement (petrosectomy), anticoagulation for 6 months | Full recovery | ||
| Zanation [] (NB: description of individual patients not provided)47 | – | Abducens nerve palsy – present in 2/4 patients | – | All 4 patients underwent petrous apex debridement (Endoscopic endonasal surgery – infrapetrous approach) | “All 4 had resolution of their acute symptoms, and both patients with abducens palsy had complete resolution by 2 months” | ||
| Isaacson [] (NB: description of individual patients not provided)94 | – | Abducens nerve palsy – present in 3/7 patients | – | – | – | ||
| Rossor []48 | – | Abducens nerve palsy, mastoiditis | IV ceftriaxone | – | Persistent abducens nerve palsy, although “continued to improve” | ||
| Loreten []49 | – | Retropharyngeal abscess, sphenoid sinusitis, meningitis | – | – | Death | ||
| Pollock [] (NB: description of individual patients not provided)95 | 3. Yes5. Yes | Abducens nerve palsy – 7/7 Cerebral venous sinus thrombosis – 6/7 Hydrocephalus – 4/7 Cavernous sinus thrombosis and proptosis – 2/7 Horner syndrome – 1/7 Parapharyngeal abscess – 1/7 | “All patients were treated with broad-spectrum antibiotics (IV followed by oral) for a total of 4–6 weeks” | Myringotomy and ventilation tube insertion – 6/7 Anticoagulation – 5/7 Mastoidectomy – 3/7 Drainage of abscess – 3/7 Antibiotics alone – 1/7 | “Ophthalmic, otolaryngologic, and neurological complications resolved in all 7 patients” | ||
| Kong []50 | – | Abducens nerve palsy, skull base osteomyelitis, torticollis | IV vancomycin, cefotaxime and metronidazole | Myringotomy and ventilation tube insertion | Full recovery | ||
| Dumas []96 | – | Facial nerve palsy, bilateral laryngeal paralysis, hearing loss, mastoiditis, meningitis, cholestasis | “Antituberculous treatment” | – | Death | ||
| Jacobsen []3 | Yes | Abducens nerve palsy, mastoiditis | IV benzylpenicillin, discharged on “20 days of IV antibiotics as a combination of cefuroxime and metronidazole” | Myringotomy and ventilation tube insertion, followed by mastoidectomy | Full recovery | ||
| Colpaert []97 | – | Abducens nerve palsy, hearing loss, mastoiditis, posterior fossa extradural empyema, partial thrombosis of sigmoid sinus | IV cefotaxime, metronidazole and clarithromycin | Adenoidectomy and bilateral placement of ventilation tubes, followed by mastoidectomy and trepanation of extradural space to evacuate empyema Anticoagulation with heparin | Mild residual hearing loss | ||
| Bhatt []98 | – | Facial and hypoglossal nerve palsies, mastoiditis | Initially IV antibiotics, once diagnosis was made switched to IV liposomal amphotericin B for 2 weeks and IV voriconazole for 12 months with IV amoxicillin and clavulanic acid for 2 months | Myringotomy, followed by mastoidectomy | Persistent complete facial nerve palsy | ||
| Lammers []51 | – | Mastoiditis and subperiosteal abscess over zygomatic arch | IV cefotaxime, flucloxacillin and metronidazole | Myringotomy and ventilation tube insertion | Full recovery | ||
| Heshin-Bekenstein []13 | – | ||||||
| Chen []99 | 4. Yes | ||||||
| Choi []52 | – | Bilateral abducens nerve palsies, hearing loss, mastoiditis | IV ceftriaxone, clindamycin and amikacin | Insertion of ventilation tube | Full recovery | ||
| Plodpai []53 | – | Abducens nerve palsy, mastoiditis | IV ceftazidime and levofloxacin | – | Full recovery | ||
| Valles []100 | – | Abducens nerve palsy, mydriasis, hearing loss, mastoiditis, meningitis, venous sinus thrombosis | IV ceftriaxone, vancomycin and ampicillin | Myringotomy | Abducens nerve palsy and mydriasis resolved Long term outcome is not stated in the report | ||
| Jensen []101 | 4. Yes | ||||||
| Janjua []102 | – | Abducens nerve palsy, extradural abscess, narrowing of petrous and cavernous segments of ICA | IV ceftriaxone | Myringotomy and ventilation tube insertion, low dose aspirin | Full recovery | ||
| Do Vale []103 | – | Mastoiditis with draining sinus, meningitis | IV ceftriaxone | Mastoidectomy and petrous apex debridement (petrectomy) | Remained in a coma in ICU, long term outcome not stated | ||
| Karunakaran []54 | – | Abducens nerve palsy, skull base osteomyelitis | IV ceftriaxone and metronidazole | – | Full recovery | ||
| Kazemi []55 | – | Abducens nerve palsy, mastoiditis, hearing loss | IV ceftazidime and clindamycin, discharged on oral amoxicillin and clavulanic acid for 2 weeks | – | Full recovery | ||
| Jensen []56 | – | Abducens and facial nerve palsies, hearing loss, mastoiditis, posterior fossa abscess | IV ceftriaxone | Myringotomy and ventilation tube insertion, deteriorated, imaging demonstrated posterior fossa abscess therefore underwent mastoidectomy and posterior fossa abscess drainage | Death | ||
| Vitale []104 | – | Abducens nerve palsy, mastoiditis, petrous apex abscess | IV ceftriaxone and metronidazole | Mastoidectomy and ventilation tube insertion | Slight lateral gaze restriction at 4-week follow-up appointment | ||
| Dorner []105 | Yes | Abducens nerve palsy, ptosis, mastoiditis, simultaneous cavitary pneumonia secondary to Actinomyces infection | IV ampicillin- sulbactam | Mastoidectomy and petrous apex debridement | Full recovery | ||
| Taklalsingh []106 | – | Trochlear and abducens nerve palsies, facial numbness, mastoiditis, meningitis, petrous apex and CPA abscesses, infection extending into foramen of Luschka | IV ceftriaxone, vancomycin, ampicillin and oral metronidazole | Myringotomy, followed by mastoidectomy and petrous apex debridement | Abducens nerve palsy resolved Persistent trochlear nerve palsy and facial numbness | ||
| Ghani []57 | – | Abducens nerve palsy | “Managed conservatively and received antibiotics for a total of 6 weeks” | – | Full recovery | ||
| Solms []58 | – | Abducens nerve palsy, mastoiditis | “Total of 10 days of parenteral antibiotics” | – | Some improvement in abducens nerve palsy, long term outcome not stated | ||
| Shapiro []107 | – | Abducens nerve palsy, mastoiditis | IV ceftazidime and vancomycin | Ventilation tube insertion | Full recovery | ||
| Gadre [] (NB: description of individual patients not provided)2 | Abducens nerve palsy – 7/44 Bilateral abducens nerve palsy – 1/44 Trigeminal neuralgic pain – 24/44 Hearing loss – 10/44 Cholesteatoma – 7/44 Dural sinus thrombosis – 4/44 Facial nerve palsy – 3/44 Ophthalmalgia (CN III, IV and VI deficits) – 2/44 Glossopharyngeal and vagus nerve palsy – 1/44 Unilateral visual loss – 1/44 CSF leak – 1/44 Meningitis – 1/44 | “All patients were treated with systemic antibiotics” Empiric antibiotic treatment: “Our current choice includes ceftriaxone along with vancomycin and metronidazole” | 34/44 (77.3%) “underwent medical management alone with or without tympanostomy and ventilation tube placement” 10/44 (22.7%) underwent major surgical intervention (petrous apex debridement) – 5/10 transmastoid – 2/10 translabyrinthine – 2/10 middle cranial fossa – 1/10 transsphenoid | One death “77.3% had resolution of their symptoms with antibiotics alone” | |||
| Brunet-Garcia []59 | – | Abducens nerve palsy, hearing loss, carotid canal bone erosion | IV antibiotics | Surgery – no description given | Full recovery | ||
| Al-juboori []60 | – | Abducens nerve palsy, hearing loss, tinnitus, mastoiditis | “Conservative treatment started with local and parenteral antimicrobial agents” | Mastoidectomy | Persistent hearing loss and tinnitus | ||
| Bozan []108 | – | Abducens nerve palsy, mastoiditis, subperiosteal abscess, cholesteatoma | IV vancomycin and cefepime | Mastoidectomy | Unclear if abducens nerve palsy resolved “The postoperative period was uneventful, and she was discharged on 30 days after operation as healthy” | ||
| Özkaçmaz []61 | – | Abducens nerve palsy, mastoiditis, sigmoid sinus thrombosis | IV ceftriaxone | Anticoagulation | Full recovery | ||
| Rossi []109 | – | Abducens nerve palsy, mastoiditis, hearing loss | IV ceftriaxone and vancomycin | Myringotomy with ventilation tube insertion and mastoidectomy | “two-week post-operative visit, she showed notable improvement in neuropathic symptoms” Resolution of hearing loss | ||
| Athapathu []62 | – | Abducens nerve palsy, mastoiditis | IV ceftazidime and vancomycin | Myringotomy and ventilation tube insertion | Full recovery | ||
| Mancini []63 | – | Mastoiditis, skull base osteomyelitis with extension into TMJ, history of chronic otitis externa with mastoidectomy | IV vancomycin, cefepime and metronidazole | – | Follow-up MRI showed persistent opacification of petrous apex and mastoid air cells | ||
| Brambilla []64 | – | – | Antibiotics | – | Full recovery | ||
| Savasta []20 | – | Abducens nerve palsy, hearing loss, petrous apex abscess | IV ceftriaxone, teicoplanin and metronidazole | – | Full recovery | ||
| McLaren []17 | – | Abducens nerve palsy, mastoiditis, cavernous sinus thrombosis, ICA arteritis | IV vancomycin, ceftriaxone, metronidazole and ciprofloxacin ear drops | Mastoidectomy and ventilation tube insertion | Full recovery | ||
| Patel []110 | 2. Yes | ||||||
| Hodges []111 | – | Abducens nerve palsy, facial pain, mastoiditis, meningitis, petrous apex cholesterol granuloma, ICA arteritis | IV ceftriaxone and vancomycin, switched to 8-week course of ceftriaxone and metronidazole | Endoscopic transsphenoidal drainage of hemosiderin- stained brown motor oil contents from the left petrous apex | “retro-orbital pain and diplopia with left lateral gaze improved gradually with treatment” | ||
| Demir []65 | – | Abducens nerve palsy, hearing loss, facial pain, meningitis, mastoiditis | IV cefoperazone, sulbactam sodium and vancomycin for 2 weeks then switched to oral amoxicillin and clavulanic acid | Myringotomy and ventilation tube insertion | Full recovery | ||
| Chandran []112 | |||||||
| Guimaraes []113 | Yes | Abducens nerve palsy, hearing loss, mastoiditis, petrous apex abscess, cavernous sinus thrombosis | IV ampicillin, metronidazole and ceftazidime and topical ciprofloxacin and hydrocortisone | Anticoagulation with heparin | Full recovery | ||
| Isaac []114 | Yes | Mastoiditis, petrous apex abscess, meningitis, ventriculitis | IV cefepime, vancomycin, metronidazole, topical ciprofloxacin and dexamethasone | Myringotomy and ventilation tube insertion followed by mastoidectomy and petrous apex debridement | Recovered with exception of hearing loss | ||
| Bergsma []15 | – | Mastoiditis, cavernous sinus thrombosis, ICA arteritis, hearing loss | IV ceftriaxone and metronidazole, discharged with 6 weeks of oral clindamycin | Anticoagulation for 3 months | Full recovery | ||
| Chowdhary []66 | – | Abducens nerve palsy, hearing loss, mastoiditis | IV penicillin and ceftriaxone | Mastoidectomy and petrous apex debridement (infralabyrinthine approach) | Full recovery | ||
| Sattarova []115 | Yes | Abducens and facial nerve palsies, facial pain, exposure keratitis, mastoiditis, subdural empyema | “patient was started on appropriate IV antibiotics” | Mastoidectomy 5 months previously | Authors have not discussed the outcome | ||
| Malic []67 | – | Abducens nerve palsy, hearing loss | IV ceftriaxone, vancomycin and metronidazole | – | Full recovery | ||
| Liu []68 | – | Abducens nerve palsy, facial numbness, mastoiditis, temporo-occipital leptomeningitis, temporal lobe cerebritis | “Broad-spectrum antibiotics” | Mastoidectomy and myringotomy, methylprednisolone | Full recovery | ||
| Quesada []116 | – | Abducens nerve palsy | IV benzylpenicillin, clindamycin and ciprofloxacin ear drops | – | Full recovery | ||
| Bonavia []117 | – | Abducens nerve palsy, facial pain, hearing loss | “6 weeks of intravenous and oral antibiotic therapy” | – | Full recovery | ||
| Bano []69 | – | Abducens, accessory and vagus nerve palsies | IV ceftriaxone and piperacillin/ tazobactam for 4 weeks | – | Full recovery | ||
| Jin []118 | – | Abducens, facial and hypoglossal nerve palsies, hearing loss, mastoiditis | Amphotericin B and oral flucytosine | Mastoidectomy | Full recovery | ||
| Chan []119 | – | Abducens nerve palsy, facial pain, mastoiditis, skull base osteomyelitis | IV cefepime for 6 weeks | Myringotomy with ventilation tube insertion and mastoidectomy | Full recovery | ||
| Kehayov []120 | – | Meningitis, seizures | IV meropenam, vancomycin and metronidazole | Initially managed with antibiotics alone, developed temporal lobe abscess requiring craniotomy for abscess drainage | Full recovery | ||
| Nassrallah []70 | – | COVID19 infection 2 weeks previously, abducens nerve palsy, facial pain and numbness | – | – | Full recovery | ||
| Saldanha []121 | – | Aplasia cutis congenita, mastoiditis, meningitis | IV ceftriaxone and vancomycin for 6 weeks | Mastoidectomy and tegmen tympani dehiscence closure with temporalis fascia | Full recovery | ||
| PA – petrous apicitis; GS – Gradenigo syndrome; OM – otitis media; OE – otitis externa; CN – cranial nerve; V1 – ophthalmic division of trigeminal nerve; Mo – months; ICA – internal carotid artery; CSF – cerebrospinal fluid; CPA – cerebellopontine angle; TMJ – temporomandibular joint; IV – intravenous; IM – intramuscular. | |||||||