Horner’s Syndrome in a Child With Otitis Media: An Unusual Complication

Abstract

Figure 1. Fat-saturated, contrast-enhanced T1 magnetic resonance image of the base of the skull. Avid contrast enhancement of the left petrous apex (arrow) is consistent with apicitis, along with thickening and enhancement of the left petrous internal carotid artery wall (black arrow). A pulsation artifact is present. A 7-year-old, previously healthy girl presented to her family physician with a 1-day history of rhinorrhea and mucoid discharge from the left ear. She was diagnosed with otitis externa and received topical antibiotics. The child was brought to the emergency department of our hospital on day 3 of her illness with a unilateral earache and discharge from the ear. Her temperature at presentation was 37.9 C. She was subsequently afebrile, and her blood pressure was normal. Examination of her ears presented evidence of inflammation of the left eardrum. No postauricular redness or swelling, no mastoid tenderness, and no protrusion of the ear were evident. She manifested ptosis of the left eye and a constricted left pupil. The drooping of her left eye had been observed by her parents on day 2 of her illness, 1 day before presentation at the hospital. Neurologic (including the cranial nerves) and general physical examinations were otherwise unremarkable. She was diagnosed with partial left Horner’s syndrome, secondary to acute otitis media. An otorrhea culture was positive for Streptococcus pyogenes (group A streptococci). She received oral amoxicillin and clavulanic acid (Augmentin; GlaxoSmithKline, Middlesex, UK) for 2 weeks. No previous history of otitis media was reported. Neuroimaging was requested. The child underwent a magnetic resonance imaging scan, followed by a computed axial tomography scan, 2 weeks after her initial presentation. Imaging revealed enhancing soft tissue material within the opacified mastoid air cell complex, middle ear cleft, and petrous apex surrounding the carotid canal on the left side, suggestive of complicated otitis media with mastoiditis, petrous apicitis, and secondary carotid involvement (Figs 1 and 2). Clinically, the partial Horner’s syndrome was unchanged, and the otorrhea had subsided. In view of the neuroimaging results, she received intravenous antibiotics for 14 days, i.e., cefotaxime for 1 week, changed because of mild thrombophlebitis to cefepime and vancomycin for the second week. A further 4-week course of oral cephalexin was prescribed (total duration of antibiotics, 8 weeks, consisting of 2 weeks oral, 2 weeks intravenous, and 4 weeks oral). A repeated magnetic resonance imaging scan 6 weeks later demonstrated a reduction in inflammatory activity in the left petrous temporal bone and a resolution of the narrowing of her