- Email: [email protected]
Acute otitis media causing visual loss: A case report and review of the literature
International Journal of Pediatric Otorhinolaryngology Extra 7 (2012) 137–138
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology Extra journal homepage: www.elsevier.com/locate/ijporl
Case report
Acute otitis media causing visual loss: A case report and review of the literature Ali K. Al-Rikabi a,*, Ben Stew b, Julia Addams-Williams b, Peter Johnson b, Sandeep Berry b a b
Maxillofacial Department, University Dental Hospital Wales, Heath Park, Cardiff CF14 4XT, United Kingdom ENT Department, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, Pontyclun, CF72 8XR
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 April 2012 Received in revised form 23 May 2012 Accepted 25 May 2012 Available online 27 June 2012
Acute otitis media (AOM) is usually self-limiting condition mainly affecting children. It may be complicated by rare but serious intra and extra cranial complications. Otitic hydrocephalus (OH) was described in 1936 by Sir Charles P. Symonds. The accepted pathophysiology is lateral cerebral sinus obliteration secondary to thrombosis and subsequent intracranial hypertension occurring after AOM. There are no clinical or serological features of meningeal irritation and no radiological features of hydrocephalus. The use of antibiotics has reduced the incidence of these complications. We report a case of permanent, bilateral visual loss secondary to AOM in an 11-year-old boy [1,2]. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Otitis media Otitic hydrocephalus Mastoidectomy Sigmoid sinus Lateral sinus
1. Case report An 11-year-old boy presented with symptoms of right otalgia, headache and otorrhoea, which followed an upper respiratory tract infection. The child was admitted to hospital and treated with intravenous and topical antibiotics. Two days later he was discharged home following systemic improvement. Within a week he was readmitted with worsening headaches and dizziness. Computed tomography (CT) demonstrated right middle ear and mastoid effusion, thrombosis of the right internal jugular vein and the sigmoid sinus with no radiological signs of hydrocephalus. A cortical mastoidectomy was performed and thrombus removed from the sigmoid sinus. Intravenous antibiotics sensitive to the Streptococcus pneumoniae culture were recommenced. The following day the child complained of blurred vision and was diagnosed with papilloedema. A second CT scan failed to identify any signs of raised intra cranial pressure (ICP). Neurosurgical and paediatric opinion was sought at this stage and the child was commenced on heparin and acetazolamide. Lumbar puncture was significant, only for an opening pressure of 80 cmH2O. This dropped to 40 cmH2O following the removal of 50 ml of cerebrospinal fluid. Repeat lumbar puncture performed three days later following reduced visual acuity and diplopia, demonstrated an opening pressure of 75 cmH2O. Neurosurgical expertise was requested at this stage and the patient underwent a ventriculo-
* Corresponding author. Tel.: +44 7816492059. E-mail address: [email protected] (A.K. Al-Rikabi). 1871-4048/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pedex.2012.05.004
peritoneal shunt. The shunt was revised on two separate occasions and eventually the child underwent a lumboperitoneal shunt. Further visual deterioration occurred and a right optic nerve fenestration was performed. Unfortunately the child suffered significant and irreversible bilateral visual loss of 1/60 in the right eye and 2/60 in the left.
2. Discussion It is widely accepted that AOM is common in children and usually self-limiting. Guidelines suggest the use of antibiotics should be limited to those who are severely ill or who remain symptomatic for greater than 48 h [3]. The risk of developing a complication of AOM is rare, with an incidence of subsequent acute mastoiditis of 1.6 per 100 000 and cerebral sinovenous thrombosis of 0.67 per 100 000 [4]. However, the middle ear cleft allows for the spread of infection from the mastoid cavity to the venous sinuses through bony dehiscence and/or thrombophlebitic spread through small emissary veins. Clinical manifestations of OH include headache, morning vomiting, abducent nerve palsy, papilloedema and diplopia [5]. The management of this aggressive condition is multifaceted and initially involves systemic antibiotic treatment and surgery. Surgical intervention may include grommet insertion, cortical mastoidectomy with or without surgical decompression of the sigmoid sinus. The use of anticoagulation is controversial and randomised controlled trials are yet to define a role in the paediatric population. Temporary lumbar drains may postpone the onset of papilloedema but lumbar or ventricular shunting is
138
A.K. Al-Rikabi et al. / International Journal of Pediatric Otorhinolaryngology Extra 7 (2012) 137–138
required should the intracranial hypertension persist and visual loss progress [6–9]. 3. Conclusion The optimal management of otitic hydrocephalus secondary to venous sinus thrombosis remains controversial but prompt recognition and treatment, with intravenous antibiotics and surgery, is paramount. References [1] C.P. Symonds, Otitic hydrocephalus, Brain 54 (1931) 55–71.
[2] M.S. Ersner, D. Meyers, Otitic hydrocephalus with a suggestion as to etiology, Annals of Otology, Rhinology and Laryngology 45 (1936) 553–566. [3] Respiratory Tract Infections – Antibiotic Prescribing, NICE, 2008. [4] M.R. Vagefi, D.R. Fredrick, Papilloedema secondary to otitic hydrocephalus, British Journal of Ophthalmology 90 (5) (2006) 646. [5] A. Tomkinson, R.G. Mills, P.J. Cantrell, The pathophysiology of otitic hydrocephalus, Journal of Laryngology and Otology 111 (8) (1997) 757–759. [6] P.L. Thompson, et al., Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the united kingdom general practice research database, Paediatrics 123 (2) (2009) 424–430. [7] S. Manolidis, J.W. Kutz Jr., Diagnosis and management of lateral sinus thrombosis, Otology and Neurotology 26 (5) (2005) 1045–1051. [8] I. Wong, F.K. Kozak, K. Poskitt, J.P. Ludemann, M. Harriman, Paediatric lateral sinus thrombosis: retrospective case series and literature review, Journal of Otolaryngology 34 (2) (2005) 79–85. [9] Pavan, et al., Preoperative and post operative intracranial complications of acute mastoiditis, Annals of Otology, Rhinology and Laryngology 118. (2) (2009) 118–123.
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology Extra journal homepage: www.elsevier.com/locate/ijporl
Case report
Acute otitis media causing visual loss: A case report and review of the literature Ali K. Al-Rikabi a,*, Ben Stew b, Julia Addams-Williams b, Peter Johnson b, Sandeep Berry b a b
Maxillofacial Department, University Dental Hospital Wales, Heath Park, Cardiff CF14 4XT, United Kingdom ENT Department, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, Pontyclun, CF72 8XR
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 April 2012 Received in revised form 23 May 2012 Accepted 25 May 2012 Available online 27 June 2012
Acute otitis media (AOM) is usually self-limiting condition mainly affecting children. It may be complicated by rare but serious intra and extra cranial complications. Otitic hydrocephalus (OH) was described in 1936 by Sir Charles P. Symonds. The accepted pathophysiology is lateral cerebral sinus obliteration secondary to thrombosis and subsequent intracranial hypertension occurring after AOM. There are no clinical or serological features of meningeal irritation and no radiological features of hydrocephalus. The use of antibiotics has reduced the incidence of these complications. We report a case of permanent, bilateral visual loss secondary to AOM in an 11-year-old boy [1,2]. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Otitis media Otitic hydrocephalus Mastoidectomy Sigmoid sinus Lateral sinus
1. Case report An 11-year-old boy presented with symptoms of right otalgia, headache and otorrhoea, which followed an upper respiratory tract infection. The child was admitted to hospital and treated with intravenous and topical antibiotics. Two days later he was discharged home following systemic improvement. Within a week he was readmitted with worsening headaches and dizziness. Computed tomography (CT) demonstrated right middle ear and mastoid effusion, thrombosis of the right internal jugular vein and the sigmoid sinus with no radiological signs of hydrocephalus. A cortical mastoidectomy was performed and thrombus removed from the sigmoid sinus. Intravenous antibiotics sensitive to the Streptococcus pneumoniae culture were recommenced. The following day the child complained of blurred vision and was diagnosed with papilloedema. A second CT scan failed to identify any signs of raised intra cranial pressure (ICP). Neurosurgical and paediatric opinion was sought at this stage and the child was commenced on heparin and acetazolamide. Lumbar puncture was significant, only for an opening pressure of 80 cmH2O. This dropped to 40 cmH2O following the removal of 50 ml of cerebrospinal fluid. Repeat lumbar puncture performed three days later following reduced visual acuity and diplopia, demonstrated an opening pressure of 75 cmH2O. Neurosurgical expertise was requested at this stage and the patient underwent a ventriculo-
* Corresponding author. Tel.: +44 7816492059. E-mail address: [email protected] (A.K. Al-Rikabi). 1871-4048/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pedex.2012.05.004
peritoneal shunt. The shunt was revised on two separate occasions and eventually the child underwent a lumboperitoneal shunt. Further visual deterioration occurred and a right optic nerve fenestration was performed. Unfortunately the child suffered significant and irreversible bilateral visual loss of 1/60 in the right eye and 2/60 in the left.
2. Discussion It is widely accepted that AOM is common in children and usually self-limiting. Guidelines suggest the use of antibiotics should be limited to those who are severely ill or who remain symptomatic for greater than 48 h [3]. The risk of developing a complication of AOM is rare, with an incidence of subsequent acute mastoiditis of 1.6 per 100 000 and cerebral sinovenous thrombosis of 0.67 per 100 000 [4]. However, the middle ear cleft allows for the spread of infection from the mastoid cavity to the venous sinuses through bony dehiscence and/or thrombophlebitic spread through small emissary veins. Clinical manifestations of OH include headache, morning vomiting, abducent nerve palsy, papilloedema and diplopia [5]. The management of this aggressive condition is multifaceted and initially involves systemic antibiotic treatment and surgery. Surgical intervention may include grommet insertion, cortical mastoidectomy with or without surgical decompression of the sigmoid sinus. The use of anticoagulation is controversial and randomised controlled trials are yet to define a role in the paediatric population. Temporary lumbar drains may postpone the onset of papilloedema but lumbar or ventricular shunting is
138
A.K. Al-Rikabi et al. / International Journal of Pediatric Otorhinolaryngology Extra 7 (2012) 137–138
required should the intracranial hypertension persist and visual loss progress [6–9]. 3. Conclusion The optimal management of otitic hydrocephalus secondary to venous sinus thrombosis remains controversial but prompt recognition and treatment, with intravenous antibiotics and surgery, is paramount. References [1] C.P. Symonds, Otitic hydrocephalus, Brain 54 (1931) 55–71.
[2] M.S. Ersner, D. Meyers, Otitic hydrocephalus with a suggestion as to etiology, Annals of Otology, Rhinology and Laryngology 45 (1936) 553–566. [3] Respiratory Tract Infections – Antibiotic Prescribing, NICE, 2008. [4] M.R. Vagefi, D.R. Fredrick, Papilloedema secondary to otitic hydrocephalus, British Journal of Ophthalmology 90 (5) (2006) 646. [5] A. Tomkinson, R.G. Mills, P.J. Cantrell, The pathophysiology of otitic hydrocephalus, Journal of Laryngology and Otology 111 (8) (1997) 757–759. [6] P.L. Thompson, et al., Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the united kingdom general practice research database, Paediatrics 123 (2) (2009) 424–430. [7] S. Manolidis, J.W. Kutz Jr., Diagnosis and management of lateral sinus thrombosis, Otology and Neurotology 26 (5) (2005) 1045–1051. [8] I. Wong, F.K. Kozak, K. Poskitt, J.P. Ludemann, M. Harriman, Paediatric lateral sinus thrombosis: retrospective case series and literature review, Journal of Otolaryngology 34 (2) (2005) 79–85. [9] Pavan, et al., Preoperative and post operative intracranial complications of acute mastoiditis, Annals of Otology, Rhinology and Laryngology 118. (2) (2009) 118–123.