- Email: [email protected]
Ophthalmic complications of otitis media in children
Ophthalmic complications of otitis media in children Travis J. Pollock, MB ChB, FCS(Ophth)SA, Peter Kim, MB BS(Hons), FRANZCO, Michael A. Sargent, MD, FRCPC, Maryam Aroichane, MD, FRCSC, Christopher J. Lyons, MB, FRCSC, and Jane A. Gardiner, MD, FRCSC PURPOSE METHODS
RESULTS
CONCLUSIONS
To evaluate the outcome of ophthalmic complications in children with otitis media. The records of children with ophthalmic complications arising from otitis media who presented to the British Columbia Children’s Hospital between August 2006 and March 2008 were reviewed retrospectively. Of 1,400 patients presenting to the emergency department for otitis media during the study period, 7 with ophthalmic complications were identified (age range, 1-11 years). All patients had abducens nerve palsy on presentation. Other notable ophthalmic complications included papilledema, Horner syndrome, and proptosis. Extracranial and intracranial complications included mastoiditis, petrositis, parapharyngeal abscess, hydrocephalus, epidural abscess, and cerebral venous thrombosis, including cavernous sinus thrombosis in 2. Of the 7 patients, 6 were treated with surgery, including myringotomy and tube placement (6 patients) and mastoidectomy (3 patients). All patients were initially anticoagulated and received intravenous antibiotics. Satisfactory final visual outcomes and stereopsis ranging from 40 to 100 seconds were achieved in all patients. Ophthalmic complications of otitis media in children are likely to include abducens palsy. All patients in our series required anticoagulation and intravenous antibiotics. Most required otolaryngologic surgery, but none required strabismus surgery, and all patients had satisfactory visual and ocular motility outcomes. ( J AAPOS 2011;15:272-275)
A
lthough the use of antibiotics has reduced complications of acute or chronic otitis media, it has become the most frequent indication for the prescription of antibiotics in children.1-5 Increased antibiotic use has increased the incidence of multiresistant organisms, and signs and symptoms of complications may be masked by previous antibiotic use.4-7 Because many cases of otitis media resolve spontaneously, in 2004, the American Academy of Pediatrics recommended an initial observation period of 2-3 days without antibiotic treatment in children with “uncomplicated” acute otitis media to reduce overuse of antibiotics.2,5,8 Although this approach should reduce antibiotic resistance, it could also lead to a resurgence of complications such as mastoiditis, meningitis, cranial nerve palsies, intracranial abscesses, cerebral venous sinus thrombosis, otitic hydrocephalus, and death.5,7,9-12 The purpose of this study is to identify the ophthalmic, Author affiliations: Department of Ophthalmology and Vision Sciences, British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC, Canada Presented at the Canadian Ophthalmological Society Annual Meeting, Quebec City, Canada, June 26-29, 2010. Submitted June 28, 2010. Revision accepted December 15, 2010. Reprint requests: Jane A. Gardiner, MD, FRCSC, A139B, Department of Ophthalmology, British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC, Canada, V6H 3V4 (email: [email protected]). Copyright Ó 2011 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2010.12.018
272
extracranial, and intracranial complications that may occur secondary to otitis media in this era of presumably reduced antibiotic use.
Methods The records of patients presenting to the Ophthalmology Department at the British Columbia Children’s Hospital (BCCH) with ophthalmic complications of otitis media from September 2006 to May 2008 were reviewed retrospectively. Ophthalmic complications included acquired esotropia, Gradenigo syndrome (otitis media, pain in the region innervated by the first and second divisions of the trigeminal nerve, and ipsilateral abducens nerve palsy), Horner syndrome, papilledema, and proptosis. Extracranial complications (mastoiditis, parapharyngeal abscess), and/or intracranial complications (cerebral venous sinus thrombosis, hydrocephalus, intracranial abscess) also were documented. This study received ethics approval from the University of British Columbia and British Columbia Children’s and Women’s Hospital Ethics committees.
Results Approximately 1,400 patients presented to the BCCH Emergency Department with otitis media during the study period; patients were referred to the ophthalmology clinic if ophthalmic complications of otitis media were noted. 7 patients (2 female) had ophthalmic complications of otitis media, and 6 of the 7 (86%) had a history of recurrent otitis media. Individual clinical cases are summarized in
Journal of AAPOS
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273
Table 1. Results of microbiology specimens Patient
Site
1 2 3 4 5
Swab (right eye) Swab (right ear) Swab (nastoid) Not performed Swab (parapharyngeal abscess)
6 7
Swab (left ear and mastoid) Swab (right ear)
Microbiology a
Corynebacterium No growth Peptostreptococcus spp.a Not performed Coagulase-negative Staphylococcusa Corynebacteriuma Abiotrophia spp.a Group A streptococcia Staphylococcus constellatus Streptococcus capitis Staphylococcus epidermidisa
Antibiotic therapy before presentation? No No Yes (oral clarithromycin) Yes (oral erythromycin) No No No
a
Normal nasopharyngeal flora.
e-Supplement 1 (available at jaapos.org); detailed case reports are available in e-Supplement 2 (available at jaapos. org). Two patients were being treated with oral antibiotics at the time of presentation. The microbiological profile in this series showed a variety of causative organisms, mostly comprising normal nasopharyngeal flora (Table 1). In our series, the ophthalmic complications of otitis media included abducens nerve palsy or Gradenigo syndrome (7 patients [100%]), papilledema (otitic hydrocephalus, 4 patients [57%]), proptosis (2 patients [29%]), and Horner syndrome (1 patient [14%]; Figures 1 and 2). All 7 patients developed esotropia secondary to abducens nerve palsy, for which 5 patients (71%) were prescribed parttime or full-time occlusion to prevent or manage amblyopia. Four patients with high intracranial pressure were treated with acetazolamide, with subsequent resolution of their papilledema. Cerebral venous sinus thrombosis occurred in 6 patients (86%), including 4 with chronic otitis media. Of the 7 patients, 2 (29%) also developed cavernous sinus thrombosis (Figure 3); orbital signs of lid swelling and proptosis were present in both. All patients were treated with broad-spectrum antibiotics (intravenous followed by oral) for a total of 4-6 weeks (e-Supplement 1). All patients were anticoagulated: 5 were treated with intravenous enoxaparin (low-molecularweight heparin), 1 with intravenous heparin, and 1 with aspirin. Six patients underwent myringotomy and tube insertion; 3, mastoidectomy; and 3, drainage of abscesses. A single patient was managed with antibiotics alone. Ophthalmic, otolaryngologic, and neurological complications resolved in all 7 patients, with normal visual acuity (Snellen 20/20) and stereopsis (4000 -10000 ) at a mean follow-up of 18 months (range, 2-36 months).
Discussion Prompt recognition and treatment of patients with ophthalmic complications of otitis media may prevent permanent neurologic and ophthalmic sequelae. A delay in presentation or misdiagnosis is associated with a greater rate of mortality.13,14 Our series suggests that a history of recurrent otitis media before presentation may be a risk factor for the development of complications.
Journal of AAPOS
FIG 1. Axial T2-weighted fluid-attenuated inversion recovery sequence showing hyperintense thrombus in the right transverse sinus in patient 4. The thrombus extended from the posterior third of the superior sagittal sinus to the proximal right jugular vein.
All 7 patients in this series presented with the complete set of symptoms of Gradenigo syndrome. The complete triad of Gradenigo syndrome may not always be manifest, especially in patients partially treated with oral antibiotics, and the absence of one presenting symptom may lead to a delay in diagnosis.15-17 This was not a concern in our series, where all patients (even those already under treatment) presented with the complete triad. Cerebral venous sinus thrombosis is attributed to either direct spread of infection from the mastoid bone or from thrombophlebitis of small emissary veins of the mastoid that communicate with the lateral sinus.18,19 The lateral sinus and sigmoid sinus are at risk since they are
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FIG 2. Axial contrast-enhanced computed tomography scan demonstrating nonocclusive thrombus (black arrow) in the left jugular bulb and an abscess collection in the right parapharyngeal space in patient 5. Note the narrowing of the right internal carotid artery posterior to the abscess (black arrowhead).
Volume 15 Number 3 / June 2011 Patients treated for otitis media are not routinely referred for ophthalmological consultation unless they develop obvious symptoms. It is possible that more patients developed milder ophthalmological complications of otitis media but were not referred because of relatively subtle findings. All patients in this series were treated with intravenous antibiotics after consultation with the infectious diseases specialist; antibiotics were continued for 4-6 weeks. No patient required thrombectomy, optic nerve decompression, ventricular shunt (lumboperitoneal or ventriculoperitoneal), or ligation of the internal jugular vein.13,16,20 All of our patients were treated with some form of anticoagulation. Shah and colleagues21 reported hemorrhagic complications in 2 children treated with enoxaparin for otogenic lateral sinus thrombosis. We therefore suggest that a hematologist be consulted before the initiation of anticoagulation therapy in such patients. No conclusive evidence links an increased incidence of otitis media complications with reduced or judicious use of antibiotics in the community, and although these cases continue to occur, our study was not designed to determine whether the incidence is changing. We suggest that clinicians maintain a high level of suspicion in patients with recurrent or persistent otologic disease, especially those with symptoms of headache, blurred vision, or diplopia.13,14 Clinicians should be particularly vigilant regarding the development of orbital symptoms, which in our series were associated with a high incidence of potentially lifethreatening cavernous sinus thrombosis.
References
FIG 3. Coronal reformat from axial contrast-enhanced computed tomography scan demonstrating filling defects in the cavernous sinus attributable to thrombus (white arrow) in patient 5. Note the right parapharyngeal abscess.
proximal to the petrous apex.1,2,16 The thrombus may subsequently propagate to involve the internal jugular vein, superior sagittal sinus, or cavernous sinus.
1. Gower D, McGuirt WF. Intracranial complications of acute and chronic infectious ear disease—a problem still with us. Laryngoscope 1983;93:1028-33. 2. Spiro DM, Arnold DH. The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr 2008;20:72-8. 3. Leibovitz E. Complicated otitis media and its implications. Vaccine 2008;265:G16-GG9. 4. Williamson I. The rocky road to rational prescribing. Vaccine 2008; 265:G11-15. 5. Meropol SB. Valuing reduced antibiotic use for pediatric acute otitis media. Pediatrics 2008;121:669-73. 6. Go C, Bernstein JM, de Jong AL, et al. Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol 2000;52:143-48. 7. Zapalac JS, Billings KR, Schwade ND, Roland PS. Suppurative complications of acute otitis media in the era of antibiotic resistance. Arch Otolaryngol Head Neck Surg 2002;128:660-63. 8. Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113:1451-65. 9. Rovers MM. The burden of otitis media. Vaccine 2008;265:G2-4. 10. Vergison A. Microbiology of otitis media: A moving target. Vaccine 2008;265:G5-10. 11. Nussinovitch M, Yoeli R, Elishkevitz K, Varano I. Acute mastoiditis in children: epidemiologic, clinical, microbiologic, and therapeutic aspects over past years. Clin Pediatr 2004;43:261-67. 12. Minotti AM, Kountakis SE. Management of abducens palsy in patients with petrositis. Ann Otol Rhinol Laryngol 1999;108:897-902. 13. Sadoghi M, Dabirmoghaddam P. Otitic hydrocephalus: Case report and literature review. Am J Otol 2007;28:187-90.
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Pollock et al
14. Ooi EH, Hilton M, Hunter G. Management of lateral sinus thrombosis: Update and literature review. J Laryngol Otol 2003;117:932-39. 15. Chole RA, Donald PJ. Petrous apicitis. Clinical considerations. Ann Otol Rhinol Laryngol 1983;92:544-51. 16. Marianowski R, Rocton S, Ait-Amer J-L, et al. Conservative management of Gradenigo syndrome in a child. Int J Pediatr Otorhinolaryngol 2001;57:79-83. 17. Sachsenweger R. Clinical localisation of oculomotor disturbances. In: Vinken PJ, Bruyn GW, editors. Handbook of Clinical Neurology. Amsterdam: University of Amsterdam; 1969.
18. Samuel A, Fernandes CMC. Lateral sinus thrombosis (A review of 45 cases). J Laryngol Otol 1987;101:1227-29. 19. Kaplan DM, Kraus M, Puterman M, et al. Otogenic lateral sinus thrombosis in children. Int J Pediatr Otorhinolaryngol 1999;49:177-83. 20. Levine SC, Souza CD. Intracranial complications of otitis media. In: Glasscock ME, Gulya AJ, editors. Surgery of the Ear. 5th ed. Hamilton: BC Decker; 2003:456-7. 21. Shah UK, Jubelirer TF, Fish JD, Elden LM. A caution regarding the use of low-molecular weight heparin in pediatric otogenic lateral sinus thrombosis. Int J Pediatr Otorhinolaryngol 2007;71:347-51.
An Eye on the Arts—The Arts on the Eye The woman seemed to have unlimited time for him. Gregorius had never had this feeling with any doctor…. He had expected her to measure the spare glasses, make the usual eye tests, and then send him to the optician with a prescription. Instead, she had him tell the history of his nearsightedness, stage after stage, concern after concern. When he finally handed her the glasses, she gave him a searching look. [. . .] The examination lasted more than an hour… Senhora Ec¸a studied the background of his eyes with the detail of somebody becoming familiar with a brand-new landscape. But what impressed Gregorius the most was that she repeated the test for visual acuity three times. In between were pauses when she had him walk back and forth and started a conversation about his profession. “How well one sees depends on so many things” she said smiling when she noted his amazement. —Pascal Mercier (from Night Train to Lisbon, Grove Press, New York, 2007)
Journal of AAPOS
275
RESULTS
CONCLUSIONS
To evaluate the outcome of ophthalmic complications in children with otitis media. The records of children with ophthalmic complications arising from otitis media who presented to the British Columbia Children’s Hospital between August 2006 and March 2008 were reviewed retrospectively. Of 1,400 patients presenting to the emergency department for otitis media during the study period, 7 with ophthalmic complications were identified (age range, 1-11 years). All patients had abducens nerve palsy on presentation. Other notable ophthalmic complications included papilledema, Horner syndrome, and proptosis. Extracranial and intracranial complications included mastoiditis, petrositis, parapharyngeal abscess, hydrocephalus, epidural abscess, and cerebral venous thrombosis, including cavernous sinus thrombosis in 2. Of the 7 patients, 6 were treated with surgery, including myringotomy and tube placement (6 patients) and mastoidectomy (3 patients). All patients were initially anticoagulated and received intravenous antibiotics. Satisfactory final visual outcomes and stereopsis ranging from 40 to 100 seconds were achieved in all patients. Ophthalmic complications of otitis media in children are likely to include abducens palsy. All patients in our series required anticoagulation and intravenous antibiotics. Most required otolaryngologic surgery, but none required strabismus surgery, and all patients had satisfactory visual and ocular motility outcomes. ( J AAPOS 2011;15:272-275)
A
lthough the use of antibiotics has reduced complications of acute or chronic otitis media, it has become the most frequent indication for the prescription of antibiotics in children.1-5 Increased antibiotic use has increased the incidence of multiresistant organisms, and signs and symptoms of complications may be masked by previous antibiotic use.4-7 Because many cases of otitis media resolve spontaneously, in 2004, the American Academy of Pediatrics recommended an initial observation period of 2-3 days without antibiotic treatment in children with “uncomplicated” acute otitis media to reduce overuse of antibiotics.2,5,8 Although this approach should reduce antibiotic resistance, it could also lead to a resurgence of complications such as mastoiditis, meningitis, cranial nerve palsies, intracranial abscesses, cerebral venous sinus thrombosis, otitic hydrocephalus, and death.5,7,9-12 The purpose of this study is to identify the ophthalmic, Author affiliations: Department of Ophthalmology and Vision Sciences, British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC, Canada Presented at the Canadian Ophthalmological Society Annual Meeting, Quebec City, Canada, June 26-29, 2010. Submitted June 28, 2010. Revision accepted December 15, 2010. Reprint requests: Jane A. Gardiner, MD, FRCSC, A139B, Department of Ophthalmology, British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC, Canada, V6H 3V4 (email: [email protected]). Copyright Ó 2011 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2010.12.018
272
extracranial, and intracranial complications that may occur secondary to otitis media in this era of presumably reduced antibiotic use.
Methods The records of patients presenting to the Ophthalmology Department at the British Columbia Children’s Hospital (BCCH) with ophthalmic complications of otitis media from September 2006 to May 2008 were reviewed retrospectively. Ophthalmic complications included acquired esotropia, Gradenigo syndrome (otitis media, pain in the region innervated by the first and second divisions of the trigeminal nerve, and ipsilateral abducens nerve palsy), Horner syndrome, papilledema, and proptosis. Extracranial complications (mastoiditis, parapharyngeal abscess), and/or intracranial complications (cerebral venous sinus thrombosis, hydrocephalus, intracranial abscess) also were documented. This study received ethics approval from the University of British Columbia and British Columbia Children’s and Women’s Hospital Ethics committees.
Results Approximately 1,400 patients presented to the BCCH Emergency Department with otitis media during the study period; patients were referred to the ophthalmology clinic if ophthalmic complications of otitis media were noted. 7 patients (2 female) had ophthalmic complications of otitis media, and 6 of the 7 (86%) had a history of recurrent otitis media. Individual clinical cases are summarized in
Journal of AAPOS
Volume 15 Number 3 / June 2011
Pollock et al
273
Table 1. Results of microbiology specimens Patient
Site
1 2 3 4 5
Swab (right eye) Swab (right ear) Swab (nastoid) Not performed Swab (parapharyngeal abscess)
6 7
Swab (left ear and mastoid) Swab (right ear)
Microbiology a
Corynebacterium No growth Peptostreptococcus spp.a Not performed Coagulase-negative Staphylococcusa Corynebacteriuma Abiotrophia spp.a Group A streptococcia Staphylococcus constellatus Streptococcus capitis Staphylococcus epidermidisa
Antibiotic therapy before presentation? No No Yes (oral clarithromycin) Yes (oral erythromycin) No No No
a
Normal nasopharyngeal flora.
e-Supplement 1 (available at jaapos.org); detailed case reports are available in e-Supplement 2 (available at jaapos. org). Two patients were being treated with oral antibiotics at the time of presentation. The microbiological profile in this series showed a variety of causative organisms, mostly comprising normal nasopharyngeal flora (Table 1). In our series, the ophthalmic complications of otitis media included abducens nerve palsy or Gradenigo syndrome (7 patients [100%]), papilledema (otitic hydrocephalus, 4 patients [57%]), proptosis (2 patients [29%]), and Horner syndrome (1 patient [14%]; Figures 1 and 2). All 7 patients developed esotropia secondary to abducens nerve palsy, for which 5 patients (71%) were prescribed parttime or full-time occlusion to prevent or manage amblyopia. Four patients with high intracranial pressure were treated with acetazolamide, with subsequent resolution of their papilledema. Cerebral venous sinus thrombosis occurred in 6 patients (86%), including 4 with chronic otitis media. Of the 7 patients, 2 (29%) also developed cavernous sinus thrombosis (Figure 3); orbital signs of lid swelling and proptosis were present in both. All patients were treated with broad-spectrum antibiotics (intravenous followed by oral) for a total of 4-6 weeks (e-Supplement 1). All patients were anticoagulated: 5 were treated with intravenous enoxaparin (low-molecularweight heparin), 1 with intravenous heparin, and 1 with aspirin. Six patients underwent myringotomy and tube insertion; 3, mastoidectomy; and 3, drainage of abscesses. A single patient was managed with antibiotics alone. Ophthalmic, otolaryngologic, and neurological complications resolved in all 7 patients, with normal visual acuity (Snellen 20/20) and stereopsis (4000 -10000 ) at a mean follow-up of 18 months (range, 2-36 months).
Discussion Prompt recognition and treatment of patients with ophthalmic complications of otitis media may prevent permanent neurologic and ophthalmic sequelae. A delay in presentation or misdiagnosis is associated with a greater rate of mortality.13,14 Our series suggests that a history of recurrent otitis media before presentation may be a risk factor for the development of complications.
Journal of AAPOS
FIG 1. Axial T2-weighted fluid-attenuated inversion recovery sequence showing hyperintense thrombus in the right transverse sinus in patient 4. The thrombus extended from the posterior third of the superior sagittal sinus to the proximal right jugular vein.
All 7 patients in this series presented with the complete set of symptoms of Gradenigo syndrome. The complete triad of Gradenigo syndrome may not always be manifest, especially in patients partially treated with oral antibiotics, and the absence of one presenting symptom may lead to a delay in diagnosis.15-17 This was not a concern in our series, where all patients (even those already under treatment) presented with the complete triad. Cerebral venous sinus thrombosis is attributed to either direct spread of infection from the mastoid bone or from thrombophlebitis of small emissary veins of the mastoid that communicate with the lateral sinus.18,19 The lateral sinus and sigmoid sinus are at risk since they are
274
Pollock et al
FIG 2. Axial contrast-enhanced computed tomography scan demonstrating nonocclusive thrombus (black arrow) in the left jugular bulb and an abscess collection in the right parapharyngeal space in patient 5. Note the narrowing of the right internal carotid artery posterior to the abscess (black arrowhead).
Volume 15 Number 3 / June 2011 Patients treated for otitis media are not routinely referred for ophthalmological consultation unless they develop obvious symptoms. It is possible that more patients developed milder ophthalmological complications of otitis media but were not referred because of relatively subtle findings. All patients in this series were treated with intravenous antibiotics after consultation with the infectious diseases specialist; antibiotics were continued for 4-6 weeks. No patient required thrombectomy, optic nerve decompression, ventricular shunt (lumboperitoneal or ventriculoperitoneal), or ligation of the internal jugular vein.13,16,20 All of our patients were treated with some form of anticoagulation. Shah and colleagues21 reported hemorrhagic complications in 2 children treated with enoxaparin for otogenic lateral sinus thrombosis. We therefore suggest that a hematologist be consulted before the initiation of anticoagulation therapy in such patients. No conclusive evidence links an increased incidence of otitis media complications with reduced or judicious use of antibiotics in the community, and although these cases continue to occur, our study was not designed to determine whether the incidence is changing. We suggest that clinicians maintain a high level of suspicion in patients with recurrent or persistent otologic disease, especially those with symptoms of headache, blurred vision, or diplopia.13,14 Clinicians should be particularly vigilant regarding the development of orbital symptoms, which in our series were associated with a high incidence of potentially lifethreatening cavernous sinus thrombosis.
References
FIG 3. Coronal reformat from axial contrast-enhanced computed tomography scan demonstrating filling defects in the cavernous sinus attributable to thrombus (white arrow) in patient 5. Note the right parapharyngeal abscess.
proximal to the petrous apex.1,2,16 The thrombus may subsequently propagate to involve the internal jugular vein, superior sagittal sinus, or cavernous sinus.
1. Gower D, McGuirt WF. Intracranial complications of acute and chronic infectious ear disease—a problem still with us. Laryngoscope 1983;93:1028-33. 2. Spiro DM, Arnold DH. The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr 2008;20:72-8. 3. Leibovitz E. Complicated otitis media and its implications. Vaccine 2008;265:G16-GG9. 4. Williamson I. The rocky road to rational prescribing. Vaccine 2008; 265:G11-15. 5. Meropol SB. Valuing reduced antibiotic use for pediatric acute otitis media. Pediatrics 2008;121:669-73. 6. Go C, Bernstein JM, de Jong AL, et al. Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol 2000;52:143-48. 7. Zapalac JS, Billings KR, Schwade ND, Roland PS. Suppurative complications of acute otitis media in the era of antibiotic resistance. Arch Otolaryngol Head Neck Surg 2002;128:660-63. 8. Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113:1451-65. 9. Rovers MM. The burden of otitis media. Vaccine 2008;265:G2-4. 10. Vergison A. Microbiology of otitis media: A moving target. Vaccine 2008;265:G5-10. 11. Nussinovitch M, Yoeli R, Elishkevitz K, Varano I. Acute mastoiditis in children: epidemiologic, clinical, microbiologic, and therapeutic aspects over past years. Clin Pediatr 2004;43:261-67. 12. Minotti AM, Kountakis SE. Management of abducens palsy in patients with petrositis. Ann Otol Rhinol Laryngol 1999;108:897-902. 13. Sadoghi M, Dabirmoghaddam P. Otitic hydrocephalus: Case report and literature review. Am J Otol 2007;28:187-90.
Journal of AAPOS
Volume 15 Number 3 / June 2011
Pollock et al
14. Ooi EH, Hilton M, Hunter G. Management of lateral sinus thrombosis: Update and literature review. J Laryngol Otol 2003;117:932-39. 15. Chole RA, Donald PJ. Petrous apicitis. Clinical considerations. Ann Otol Rhinol Laryngol 1983;92:544-51. 16. Marianowski R, Rocton S, Ait-Amer J-L, et al. Conservative management of Gradenigo syndrome in a child. Int J Pediatr Otorhinolaryngol 2001;57:79-83. 17. Sachsenweger R. Clinical localisation of oculomotor disturbances. In: Vinken PJ, Bruyn GW, editors. Handbook of Clinical Neurology. Amsterdam: University of Amsterdam; 1969.
18. Samuel A, Fernandes CMC. Lateral sinus thrombosis (A review of 45 cases). J Laryngol Otol 1987;101:1227-29. 19. Kaplan DM, Kraus M, Puterman M, et al. Otogenic lateral sinus thrombosis in children. Int J Pediatr Otorhinolaryngol 1999;49:177-83. 20. Levine SC, Souza CD. Intracranial complications of otitis media. In: Glasscock ME, Gulya AJ, editors. Surgery of the Ear. 5th ed. Hamilton: BC Decker; 2003:456-7. 21. Shah UK, Jubelirer TF, Fish JD, Elden LM. A caution regarding the use of low-molecular weight heparin in pediatric otogenic lateral sinus thrombosis. Int J Pediatr Otorhinolaryngol 2007;71:347-51.
An Eye on the Arts—The Arts on the Eye The woman seemed to have unlimited time for him. Gregorius had never had this feeling with any doctor…. He had expected her to measure the spare glasses, make the usual eye tests, and then send him to the optician with a prescription. Instead, she had him tell the history of his nearsightedness, stage after stage, concern after concern. When he finally handed her the glasses, she gave him a searching look. [. . .] The examination lasted more than an hour… Senhora Ec¸a studied the background of his eyes with the detail of somebody becoming familiar with a brand-new landscape. But what impressed Gregorius the most was that she repeated the test for visual acuity three times. In between were pauses when she had him walk back and forth and started a conversation about his profession. “How well one sees depends on so many things” she said smiling when she noted his amazement. —Pascal Mercier (from Night Train to Lisbon, Grove Press, New York, 2007)
Journal of AAPOS
275