Case ReportGradenigo Syndrome Without Acute Otitis Media
Introduction
Gradenigo syndrome, which was first described in 1907 by Giuseppe Gradenigo, consists of otitis media, facial pain in the trigeminal territory, and ipsilateral abducens nerve palsy due to a petrous apicitis [1]. Acute otitis media complications are increasingly less common, thanks to the more widespread availability and use of adequate antibiotic therapy [2]. When they do occur, however, they may be inconspicuous or silent but with dangerous evolution [3], [4]. The atypical symptoms require special attention. The petrous apex is part of the temporal bone located deep in the skull; it is in contact with the cranial nerves, vascular structures, the dura and the brain. The petrous apex is situated at the top of the petrous pyramid and communicates with the middle ear (cleft and mastoid) by a route of well-aerated cells.
Described here is the clinical and neuroimaging evolution of a child with an atypical Gradenigo syndrome without clinical otitis media at the moment of diagnosis which was managed medically with favorable outcome.
Section snippets
Case Report
A 5-year-old boy was admitted to the otolaryngology department at the authors' institution, a primary care center. He had been admitted 5 weeks earlier to the emergency unit of a tertiary care hospital for headaches, fever, and vomiting. His previous medical history was unremarkable, except for a varicella infection 1 month earlier. Polymorphonuclear neutrophils were at 21,845/mm3 (reference range, 1900-8000) and C-reactive protein was at 174 mg/L (reference range, 0.0-5.0). Lumbar puncture
Anatomical Considerations
The petrous apex is a pyramid-shaped bone that lies between the inner ear and the clivus in the most medial portion of the temporal bone. It surrounds the internal auditory canal, which divides it into anterior and posterior portions [5]. Although 80% of mastoid bones are pneumatized, only 30% of petrous apex bones have air cells communicating with the middle ear cleft [6]. The boundaries of the petrous apex include many important neurologic and vascular structures, which may be affected by an
Conclusion
Gradenigo syndrome is a rare but life-threatening complication of acute otitis media. It is not always complete [9] or acute, so vigilance is required in the face of any atypical symptoms after acute otitis media. More often than not, treatment is medical. Surgical treatment should be performed if there is a life-threatening complication or if a pus sample must be obtained by mastoid drainage. A major difficulty concerning treatment is determining the duration of the treatment and which
References (17)
- et al.
Gradenigo syndrome: a case report and review of a rare complication of otitis media
J Emerg Med
(2004) - et al.
Streptococcus acidominimus infection in a child causing Gradenigo syndrome
Int J Pediatr Otorhinolaryngol
(2003) - et al.
Conservative management of Gradenigo syndrome in a child
Int J Pediatr Otorhinolaryngol
(2001) - et al.
Acute onset of abducens nerve palsy in a child with prior history of otitis media: a misleading sign of Gradenigo syndrome
Brain Dev
(2005) - et al.
Gradenigo syndrome as presenting sign of T-cell lymphoma
Pediatr Neurol
(1989) - et al.
Clinical and magnetic resonance imaging features of Gradenigo syndrome
Am J Ophthalmol
(1997) On paralysis of the nervus abducens in otitis
Arch Ohrenheilk
(1907)- et al.
Gradenigo syndrome: still a threatening complication of otitis media
HNO
(2005)
Cited by (16)
Fatal embryonic rhabdomyosarcoma with leptomeningeal metastases debuting as Gradenigo syndrome: Case report and literature review
2020, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementCitation Excerpt :In our case MRI showed a mass involving the petrous apex, temporal bone and infratemporal fossa that explains the neurological deficit of the patient. The involvement of neurologic and vascular structures related to the petrous apex can cause deficits of the cranial nerves II to X depending on whether the pathological process extends to the skull base or the cavernous sinus [9]. In contrast to other reports, our patient received radical mastoidectomy and chemotherapy [1,8].
How well do we know Gradenigo? A comprehensive literature review and proposal for novel diagnostic categories of Gradenigo's syndrome
2020, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Including our patient, 106 children were used in the final analysis and subsequently classified within the three proposed diagnostic categories. Forty-five patients, including ours, met criteria for classic GS [6–46], with a mean age of 8.5 (SD ± 3.9) years, and twenty patients were categorized as having incomplete GS [47–63], with a mean age of 7.0 (SD ± 4.2) years. A summary of the clinical features, diagnostic workup, therapeutics and outcomes for patients with classic and incomplete GS is outlined in Table 2.
Cranial Osteomyelitis: A Comprehensive Review of Modern Therapies
2018, World NeurosurgeryCitation Excerpt :Other symptoms can include severe headache, photophobia, meningeal signs, fever, diplopia, and reduced corneal sensitivity.53-57 The most common etiologic pathogens are Staphylococcus aureus, Streptococcus pneumoniae, group A streptococci, Pseudomonas, and nontypeable Haemophilus influenzae.58 Traditionally, Gradenigo syndrome has been treated by surgery; however, surgery is reserved for refractory cases.
Gradenigo syndrome and petrositis in a child
2015, Archives de PediatrieGradenigo's syndrome: The importance of general pediatric examination
2011, Anales de PediatriaAcute otitis media-induced petrous apicitis presenting as the Gradenigo syndrome: Successfully treated by ventilation tube insertion
2011, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :However, spread of the infection beyond that area is still observed in some patients. Recent reports have documented good results by using more conservative therapy with high-dose broad-spectrum antibiotics that have intracranial penetration [11,12]. We have demonstrated that patients developing petrous apicitis with Gradenigo syndrome responded to antibiotic therapy and ventilation tube insertion.