An Atypical Pediatric Headache: Outpatient Presentation of Petrous Apicitis With Cerebral Venous Sinus Thrombosis

Severe complications of acute otitis media (AOM) are rare in the United States due to widespread antibiotic use. One severe complication of AOM is the contiguous spread of infection to the petrous apex of the temporal bone, causing petrous apicitis. Due to its proximity to the dural venous sinuses, petrous apicitis can lead to a septic cerebral venous sinus thrombosis (CVST). The presentation of these complications is discussed here in the case of an 8-year-old male.

An 8-year-old male with no significant past medical history presented to an outpatient clinic with a history of intermittent headaches. Examination revealed bilateral papilledema, swelling behind the right ear, and a right middle ear effusion, resulting in a prompt referral to the emergency department. Imaging demonstrated mastoiditis, petrous apicitis, and thrombosis of the right sigmoid and transverse sinuses extending into the internal jugular vein. He was admitted to the pediatric intensive care unit and treated with anticoagulation, empiric antibiotics, and acetazolamide for intracranial hypertension. His course was complicated by the development of abducens neuropathy and somnolence, and he underwent right mastoidectomy with sigmoid sinus decompression. Intraoperative cultures grew Streptococcus intermedius. Postoperatively, he improved clinically, though persistent papilledema and abducens nerve palsy were noted. He was discharged after a ten-day inpatient stay on a regimen of oral antibiotics, rivaroxaban, and acetazolamide, with multidisciplinary follow-up.

Petrous apicitis with septic CVST is a rare but life-threatening complication of AOM. This case emphasizes the need for vigilance in children presenting with severe or persistent neurologic symptoms in the setting of prior otologic symptoms. Prompt recognition and treatment are critical to reducing morbidity and preventing long-term neurologic sequelae.