Case Presentation:

A 14-year-old male with a 1½-month history of recurrent otitis media presented with intermittent headaches, emesis and a 20lb weight loss. General appearance significant for new onset strabismus. One month prior to presentation, reported 1 week of fever subsequently treated with 5 days of amoxicillin for bilateral otitis media; later changed to 10 days of cefdinir due to persistent symptoms.

Upon evaluation, vital signs were within normal limits. Physical exam revealed multiple dental caries, left abducens nerve palsy, and white purulent drainage from a left tympanic membrane defect. Fundoscopic exam showed significant papilledema. No mastoid process erythema, tenderness, or warmth on exam. Normal white blood cell count, inflammatory markers and negative HIV antibodies. Brain MRI demonstrated a left transverse and sigmoid dural venous sinus thrombosis extending to the left jugular foramen (confirmed on MR venography) and left mastoiditis. A CT confirmed the mastoiditis and associated otitis media with erosion into the left incus and petrous temporal bone.

He ultimately underwent a mastoidectomy, tympanostomy tube placement, and drainage of a Bezold abscess. Surgical cultures grew Enterobacter aerogenes, Streptococcus anginosus, and Pseudomonas putidaBased on sensitivities, he was treated with a 6-week course of cefepime and metronidzole. Dentistry performed extractions of 6 teeth prior to discharge given his severe dental disease. His symptoms above resolved during admission and his appetite improved.

Discussion:

This case describes a patient with chronic suppurative otitis media as well as multiple dental caries leading to complications of mastoiditis, Gradenigo’s syndrome, dural venous sinus thrombosis, and Bezold abscess. Gradenigo’s syndrome is historically defined as the triad of suppurative otitis media, facial pain distributed along the trigeminal nerve (lacking in this case), and abducens nerve palsy; with the latter two occurring secondary to infectious spread to the petrous apex. Either direct extension of the infection or adjacent inflammation of the temporal bone led to a reactive thrombophlebitis leading to this patient’s lateral sinus venous thrombosis. Bezold abscess ensued after infectious erosion of the mastoid process and spread between digastrics and sternocleidomastoid muscles. Additional complication of severe dental disease likely contributed to the Streptococcus anginosus growth on culture.

Conclusions:

This case demonstrates the many complications of acute otitis media, with most becoming increasingly rare since the since the advent of antibiotics. Early recognition of these complications is extremely important given their potential grave consequences. It is also important to not overlook other potential sources for infection, like odontogenic sources, when exploring reasons for persistent symptoms in the face of first line treatments.