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Silent mastoiditis and bilateral simultaneous facial palsy
International Journal of Pediatric Otorhinolaryngologv, 5 (1983) 303-307
303
Elsevier
Silent mastoiditis and bilateral simultaneous facial palsy Ferit Tovi * and Alberto L e i b e r m a n Ear, Nose and Throat Department, Soroka University Hospital and Faculty of Health Sciences, Ben -Gurion University of the Negev. Beer-Sheba (Israel)
(Received January 21st. 1983) (Accepted February 18th, 1983)
Key words: silent mastoiditis - - bilateral facial palsy
Summary Silent mastoiditis is a c o m m o n c o m p l i c a t i o n of acute otitis m e d i a since the advent o f antibiotics. A l t h o u g h most pediatric m i d d l e ear i n f l a m m a t i o n s manifest themselves in both ears, otitic facial palsy almost always presents unilaterally. W e report an unusual case of bilateral simultaneous facial palsy occurring during the course of a persistent otitis m e d i a in a 7 - m o n t h - o l d child. A p p r o p r i a t e antibiotic t h e r a p y and insertion of ventilating tubes cleared the infectious i n f l a m m a t o r y process, resulting in full recovery from nerve dysfunction.
Introduction Bilateral s i m u l t a n e o u s facial palsy is rather an u n c o m m o n condition. It accounts for 1.6% of all facial palsy cases [13]. N u m e r o u s diseases were found to be associated with this n e u r o p a t h y [3]. Infectious i n f l a m m a t o r y processes affecting the central nervous system or the peripheral nerves a p p e a r to be a c o m m o n etiology [6]. Viral diseases [17], mainly infectious mononucleosis [2,12,21]. bacterial [3,5] and even parasitic infections [1,3] have been r e p o r t e d as etiological factors. Otitis media, as a local infection, m a y also c o m p r o m i s e the facial nerve. Segmental affection of the nerve occurs mostly in p e d i a t r i c acute m i d d l e ear infections [18].
* Corresponding author and address for reprints: Ferit Tovi, M.D., Ear. Nose and Throat Department, Soroka Medical Center, P.O. Box 151, Beer-Sheba 84-101, Israel. 0165-5876/83/$03.00 © 1983 Elsevier Science Publishers B.V.
304
Although this infection in the early years of age manifests itself in both ears [15,16], review of the literature shows that otitic facial palsy presents almost always unilaterally. As far as we know bilateral facial palsy as a complication of acute otitis media has been cited only by Ganz [3]. In this report we find it of clinical interest to present an unusual case of bilateral facial palsy in a child suffering from a latent otitis media.
Case Report A 7-month-old girl was referred to the E.N.T. Department because of bilateral weakness of the facial musculature which appeared following 4 consecutive bouts of otitis media in a 3-week period. During this period she underwent bilateral paracentesis 3 times and received ampicillin therapy of 100 m g / k g daily for 5 days after
Fig. I. Bilateral paralysis of both facial nerves. Picture taken at crying.
305 each procedure. A transient relief of the clinical symptomatology had been observed after each paracentesis. Difficulty in eating and absence of mimic expression in emotional responses were detected the day before referral. On admission she was subfebrile (37.5°C), otherwise the general physical examination was normal. Otolaryngologic examination revealed bilateral bulging, greyish-pink tympanic membranes with loss of landmarks. The postauricular areas were found slightly tender in palpation but showed no inflammatory signs. Bilateral complete facial palsy was present (Fig. 1). Equal reflex lacrimation was found in Schrimmer's test. Routine blood count and chemistry as well as urine analysis were normal. X-ray examination of temporal bones showed cloudiness of both mastoid antrums and periantral cells, without evidence of destruction of bony cell walls. Under sterile conditions bilateral paracentesis with insertion of ventilating tubes was performed. Purulent discharge was collected from both ears. Staphylococcus aureus sensitive to cephalosporins was cultured from the material remaining on the paracentesis knives. The patient was given Cephalexin therapy 50 m g / k g daily. Ten days later the purulent discharge ceased. Gradual amelioration of the bilateral facial palsy was observed in the follow-up. Six weeks later full recovery took place.
Discussion Acute otitis media is an extremely common disease of childhood. Usually it tends to be self-limited; sometimes because of inadequate therapy or because of decreased immunity of the host a n d / o r high virulency of the pathogenic organism, the infectious inflammatory process progresses in stages and may involve the neigl~bouring structures of the middle ear cleft. With the advent of antibiotics the frequency of such a complication has decreased [7]. Facial palsy as a complication of middle ear infection is rare. It occurs in less than 0.02% [14] of the acute otitis media cases. It accounts for 7% of all pediatric acute otitis media complications [7] and 10-16% of all peripheral facial palsy cases of childhood [I0,11]. Peripheral facial palsy in acute otitis media, occurring in the early stages of the disease, is of inflammatory toxic origin, similar to Bell's palsy [19]. When it appears late during the course of acute otitis media, it is usually related to coalescent mastoiditis, where erosion of the mastoid cell walls and fallopian canal occurs. Another potential condition for otitic facial palsy is silent mastoiditis. This condition is a common complication of acute middle ear infection since the introduction of antibiotics [20]. The inadequate antibiotic therapy provides a transient relief of the clinical symptomatology, while the persistent inflammatory process in the middle ear cleft progresses in a silent manner and gives rise to several exacerbations in a short time period. Intratemporal or intracranial complications may occur. Staphylococci, with the exception of newborns, form an infrequent pathogen in pediatric acute middle ear infections [8]. They are found mainly in persistent otitis media cases [4]. The multiple bouts of otitis media in a 3-week period, the occurence of facial
306
Fig. 2. Six weeks after treatment. Full recoveryof both facial nerves. Picture taken at crying.
palsy late in the course of the disease, and the presence of staphylococci together with the absence of bone destruction in r6ntgenologic studies, point in our case to a silent mastoiditis. Bony dehiscence of the fallopian canal enhances the risk of facial palsy in middle ear inflammations. Leonard and Alexander [9] reported symmetrical, bilateral dehiscences of the fallopian canal at the oval window area in 24 of 200 ears. Such an anomaly may explain the simultaneous involvement of both facial nerves by the infectious inflammatory process. The administration of appropriate antibiotics and insertion of ventilating tubes cleared the persistent inflammation in both ears, resulting in full recovery from the bilateral facial palsy (Fig. 2).
307
References I Duc, G., Jungo, O. and Gugler, E., Bilateral facial paralysis and acquired toxoplasmosis in a four-year-old child, Heir. paediat. Acta, 19 (1964) 207-212. 2 Egan, R.W., Facial diplegia complicating infectious mononucleosis in the absence of Landry-Guillain Barre Syndrome, New Engl. J. Med., 262 (1960) 1178-1179. 3 Ganz, H., Incidence of bilateral facial palsy with special reference to its isolated rheumatic form, Aerztl. Wochenschr., 13 (1958) 733-737. 4 Gronross, A., Kortekangas, E., Ojala, L. and Vuori, M., The etiology of acute middle ear infection, Acta oto-laryng., 58 (1964) 149-158. 5 Hohenegger, M., Bilateral facial paresis as the only symptom of a staphylococcus meningitis, Wien. Med. Wochenschr., 116 (1966) 182-183. 6 Holla, S.P., Smith, R.R. and Sanford, R.A., Bilateral traumatic facial paralysis, Neurosurgery, 6 (1980) 290-292. 7 Kaltiskallis, J.H., Complications of acute and chronic otitis media in antibiotic era. Acta oto-laryng., 74 (1972) 445-450. 8 Klein, J.O., Microbiology and antimicrobal treatment of otitis media, Ann. Otol., Suppl. 84 90 (1981) 30-36. 9 Leonard, J.R. and Alexander, D.M., Anatomic variations in the area of the oval windows, Arch. Otolaryng. 87 (1968) 48-55. 10 Lloyd, A N . C , Jewitt, D.E. and Still, D.D.L., Facial paralysis in children with hypertension, Arch. Dis. Childh., 41 (1966) 292-294. 11 Manning, J.J. and Adour, K.K., Facial paralysis in children, Pediatrics, 49 (1972) 102-109. 12 Mednonca, D., A case of infectious mononucleosis presenting with bilateral facial palsy, J. Laryng., 85 (1971) 981-982. 13 Merwath, H.R., cited by McGovern, F.H., Bilateral Bell's palsy, Laryngoscope, (1966) 1070-1080. 14 Paovolainen, M., Incidence, etiology and prognosis in acute purulent otitis media in Helsinki residents of various ages, Acta oto-laryng., Suppl., 224 (1967) 360-371. 15 Ronning, O. and Gardborg, O., A clinical and bacteriological examination of a series of cases of otitis as regard to the significance of resistent determinations, Acta oto-laryng., 44 (1954) 161-174. 16 Rubinstein, M.M., McBean, J.B., Hedgecock, Le Roy D. and Stickler, G.B., A treatment of acute otitis media in children. Amer. J. Dis. Childh., 109 (1965) 308-313. 17 Schurring, A., Facial diplegia - - a viral disease, Arch. Otolaryng., 80 (1964) 103-105. 18 Schurring, A.G. and Gunter, J.P., Paralysis of the facial nerve in children, Clin. Pediat., 9 (1970) 105-109. 19 Shambough, G.E. and Glasscock, M.E., Surgery of the Ear (3rd edn.), Saunders, Philadelphia, 1980, p. 345. 20 Stuart Mawson. In J. Ballantyne and J. Groves (Eds.), Scott-Brown's Disease of the Ear, Nose and Throat (4th edn., Vol. 1), Butterworths, London, 1979, p. 190. 21 Werntraub, M.I., Bilateral facial palsy, a rare presentation of infectious mononucleosis, Clin. Pediat., 16 (1977) 1158-1159.
303
Elsevier
Silent mastoiditis and bilateral simultaneous facial palsy Ferit Tovi * and Alberto L e i b e r m a n Ear, Nose and Throat Department, Soroka University Hospital and Faculty of Health Sciences, Ben -Gurion University of the Negev. Beer-Sheba (Israel)
(Received January 21st. 1983) (Accepted February 18th, 1983)
Key words: silent mastoiditis - - bilateral facial palsy
Summary Silent mastoiditis is a c o m m o n c o m p l i c a t i o n of acute otitis m e d i a since the advent o f antibiotics. A l t h o u g h most pediatric m i d d l e ear i n f l a m m a t i o n s manifest themselves in both ears, otitic facial palsy almost always presents unilaterally. W e report an unusual case of bilateral simultaneous facial palsy occurring during the course of a persistent otitis m e d i a in a 7 - m o n t h - o l d child. A p p r o p r i a t e antibiotic t h e r a p y and insertion of ventilating tubes cleared the infectious i n f l a m m a t o r y process, resulting in full recovery from nerve dysfunction.
Introduction Bilateral s i m u l t a n e o u s facial palsy is rather an u n c o m m o n condition. It accounts for 1.6% of all facial palsy cases [13]. N u m e r o u s diseases were found to be associated with this n e u r o p a t h y [3]. Infectious i n f l a m m a t o r y processes affecting the central nervous system or the peripheral nerves a p p e a r to be a c o m m o n etiology [6]. Viral diseases [17], mainly infectious mononucleosis [2,12,21]. bacterial [3,5] and even parasitic infections [1,3] have been r e p o r t e d as etiological factors. Otitis media, as a local infection, m a y also c o m p r o m i s e the facial nerve. Segmental affection of the nerve occurs mostly in p e d i a t r i c acute m i d d l e ear infections [18].
* Corresponding author and address for reprints: Ferit Tovi, M.D., Ear. Nose and Throat Department, Soroka Medical Center, P.O. Box 151, Beer-Sheba 84-101, Israel. 0165-5876/83/$03.00 © 1983 Elsevier Science Publishers B.V.
304
Although this infection in the early years of age manifests itself in both ears [15,16], review of the literature shows that otitic facial palsy presents almost always unilaterally. As far as we know bilateral facial palsy as a complication of acute otitis media has been cited only by Ganz [3]. In this report we find it of clinical interest to present an unusual case of bilateral facial palsy in a child suffering from a latent otitis media.
Case Report A 7-month-old girl was referred to the E.N.T. Department because of bilateral weakness of the facial musculature which appeared following 4 consecutive bouts of otitis media in a 3-week period. During this period she underwent bilateral paracentesis 3 times and received ampicillin therapy of 100 m g / k g daily for 5 days after
Fig. I. Bilateral paralysis of both facial nerves. Picture taken at crying.
305 each procedure. A transient relief of the clinical symptomatology had been observed after each paracentesis. Difficulty in eating and absence of mimic expression in emotional responses were detected the day before referral. On admission she was subfebrile (37.5°C), otherwise the general physical examination was normal. Otolaryngologic examination revealed bilateral bulging, greyish-pink tympanic membranes with loss of landmarks. The postauricular areas were found slightly tender in palpation but showed no inflammatory signs. Bilateral complete facial palsy was present (Fig. 1). Equal reflex lacrimation was found in Schrimmer's test. Routine blood count and chemistry as well as urine analysis were normal. X-ray examination of temporal bones showed cloudiness of both mastoid antrums and periantral cells, without evidence of destruction of bony cell walls. Under sterile conditions bilateral paracentesis with insertion of ventilating tubes was performed. Purulent discharge was collected from both ears. Staphylococcus aureus sensitive to cephalosporins was cultured from the material remaining on the paracentesis knives. The patient was given Cephalexin therapy 50 m g / k g daily. Ten days later the purulent discharge ceased. Gradual amelioration of the bilateral facial palsy was observed in the follow-up. Six weeks later full recovery took place.
Discussion Acute otitis media is an extremely common disease of childhood. Usually it tends to be self-limited; sometimes because of inadequate therapy or because of decreased immunity of the host a n d / o r high virulency of the pathogenic organism, the infectious inflammatory process progresses in stages and may involve the neigl~bouring structures of the middle ear cleft. With the advent of antibiotics the frequency of such a complication has decreased [7]. Facial palsy as a complication of middle ear infection is rare. It occurs in less than 0.02% [14] of the acute otitis media cases. It accounts for 7% of all pediatric acute otitis media complications [7] and 10-16% of all peripheral facial palsy cases of childhood [I0,11]. Peripheral facial palsy in acute otitis media, occurring in the early stages of the disease, is of inflammatory toxic origin, similar to Bell's palsy [19]. When it appears late during the course of acute otitis media, it is usually related to coalescent mastoiditis, where erosion of the mastoid cell walls and fallopian canal occurs. Another potential condition for otitic facial palsy is silent mastoiditis. This condition is a common complication of acute middle ear infection since the introduction of antibiotics [20]. The inadequate antibiotic therapy provides a transient relief of the clinical symptomatology, while the persistent inflammatory process in the middle ear cleft progresses in a silent manner and gives rise to several exacerbations in a short time period. Intratemporal or intracranial complications may occur. Staphylococci, with the exception of newborns, form an infrequent pathogen in pediatric acute middle ear infections [8]. They are found mainly in persistent otitis media cases [4]. The multiple bouts of otitis media in a 3-week period, the occurence of facial
306
Fig. 2. Six weeks after treatment. Full recoveryof both facial nerves. Picture taken at crying.
palsy late in the course of the disease, and the presence of staphylococci together with the absence of bone destruction in r6ntgenologic studies, point in our case to a silent mastoiditis. Bony dehiscence of the fallopian canal enhances the risk of facial palsy in middle ear inflammations. Leonard and Alexander [9] reported symmetrical, bilateral dehiscences of the fallopian canal at the oval window area in 24 of 200 ears. Such an anomaly may explain the simultaneous involvement of both facial nerves by the infectious inflammatory process. The administration of appropriate antibiotics and insertion of ventilating tubes cleared the persistent inflammation in both ears, resulting in full recovery from the bilateral facial palsy (Fig. 2).
307
References I Duc, G., Jungo, O. and Gugler, E., Bilateral facial paralysis and acquired toxoplasmosis in a four-year-old child, Heir. paediat. Acta, 19 (1964) 207-212. 2 Egan, R.W., Facial diplegia complicating infectious mononucleosis in the absence of Landry-Guillain Barre Syndrome, New Engl. J. Med., 262 (1960) 1178-1179. 3 Ganz, H., Incidence of bilateral facial palsy with special reference to its isolated rheumatic form, Aerztl. Wochenschr., 13 (1958) 733-737. 4 Gronross, A., Kortekangas, E., Ojala, L. and Vuori, M., The etiology of acute middle ear infection, Acta oto-laryng., 58 (1964) 149-158. 5 Hohenegger, M., Bilateral facial paresis as the only symptom of a staphylococcus meningitis, Wien. Med. Wochenschr., 116 (1966) 182-183. 6 Holla, S.P., Smith, R.R. and Sanford, R.A., Bilateral traumatic facial paralysis, Neurosurgery, 6 (1980) 290-292. 7 Kaltiskallis, J.H., Complications of acute and chronic otitis media in antibiotic era. Acta oto-laryng., 74 (1972) 445-450. 8 Klein, J.O., Microbiology and antimicrobal treatment of otitis media, Ann. Otol., Suppl. 84 90 (1981) 30-36. 9 Leonard, J.R. and Alexander, D.M., Anatomic variations in the area of the oval windows, Arch. Otolaryng. 87 (1968) 48-55. 10 Lloyd, A N . C , Jewitt, D.E. and Still, D.D.L., Facial paralysis in children with hypertension, Arch. Dis. Childh., 41 (1966) 292-294. 11 Manning, J.J. and Adour, K.K., Facial paralysis in children, Pediatrics, 49 (1972) 102-109. 12 Mednonca, D., A case of infectious mononucleosis presenting with bilateral facial palsy, J. Laryng., 85 (1971) 981-982. 13 Merwath, H.R., cited by McGovern, F.H., Bilateral Bell's palsy, Laryngoscope, (1966) 1070-1080. 14 Paovolainen, M., Incidence, etiology and prognosis in acute purulent otitis media in Helsinki residents of various ages, Acta oto-laryng., Suppl., 224 (1967) 360-371. 15 Ronning, O. and Gardborg, O., A clinical and bacteriological examination of a series of cases of otitis as regard to the significance of resistent determinations, Acta oto-laryng., 44 (1954) 161-174. 16 Rubinstein, M.M., McBean, J.B., Hedgecock, Le Roy D. and Stickler, G.B., A treatment of acute otitis media in children. Amer. J. Dis. Childh., 109 (1965) 308-313. 17 Schurring, A., Facial diplegia - - a viral disease, Arch. Otolaryng., 80 (1964) 103-105. 18 Schurring, A.G. and Gunter, J.P., Paralysis of the facial nerve in children, Clin. Pediat., 9 (1970) 105-109. 19 Shambough, G.E. and Glasscock, M.E., Surgery of the Ear (3rd edn.), Saunders, Philadelphia, 1980, p. 345. 20 Stuart Mawson. In J. Ballantyne and J. Groves (Eds.), Scott-Brown's Disease of the Ear, Nose and Throat (4th edn., Vol. 1), Butterworths, London, 1979, p. 190. 21 Werntraub, M.I., Bilateral facial palsy, a rare presentation of infectious mononucleosis, Clin. Pediat., 16 (1977) 1158-1159.