1
|
Fontani E, Branda E, Denina M, Baroero L, Canavese C, Mignone F, Giordano P, Conrieri M, Versace A, Bondone C. Abducens nerve palsy in a young girl with otorrhea: A case of Gradenigo's syndrome. Pediatr Neonatol 2024:S1875-9572(24)00114-1. [PMID: 39004540 DOI: 10.1016/j.pedneo.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/09/2024] [Accepted: 06/04/2024] [Indexed: 07/16/2024] Open
Affiliation(s)
- Eleonora Fontani
- Department of Pediatrics and Public Health, Regina Margherita Children's Hospital, Turin, Italy
| | - Elena Branda
- Department of Pediatrics and Public Health, Regina Margherita Children's Hospital, Turin, Italy
| | - Marco Denina
- Infectious disease unit, Department of Pediatrics, Regina Margherita Children's Hospital, Turin, Italy; Department of Pediatric Emergency, Regina Margherita Children's Hospital, Turin, Italy.
| | - Luca Baroero
- Department of Pediatrics, Martini Hospital, Turin, Italy
| | - Carlotta Canavese
- Pediatric neurology unit, Department of Pediatrics, Regina Margherita Pediatric Children's, Turin, Italy
| | - Federica Mignone
- Infectious disease unit, Department of Pediatrics, Regina Margherita Children's Hospital, Turin, Italy
| | - Pamela Giordano
- Pediatric Otorhinolaryngology, Department of Pediatrics, Regina Margherita Children's Hospital, Turin, Italy
| | - Margherita Conrieri
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, Turin, Italy
| | - Antonia Versace
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, Turin, Italy
| | - Claudia Bondone
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, Turin, Italy
| |
Collapse
|
2
|
Abstract
INTRODUCTION Petrous apicitis (PA) is a rare but dangerous complication of acute otitis media. The objective of this study is to present a case of PA and systematically review the existing literature on PA to characterize clinical presentation, diagnosis, management, and outcomes in the antibiotic era. METHODS A comprehensive search from 1983 to June 1, 2020, of PubMed, MEDLINE, Cochrane Library, and EmBase databases was conducted. Studies with clinical data regarding patients with PA were included. Non-English literature or studies with insufficient individual patient data were excluded. Sixty-seven studies were included with a total of 134 patients. RESULTS A total of 67 articles were found to meet criteria for inclusion. The mean age of presentation was 33 years. Recent acute otitis media was reported in 78 patients (58.2%). Only 3 patients (2.2%) were immunocompromised, and 8 patients (6.0%) had a history of diabetes. Gradenigo's triad of abducens palsy, otorrhea, and retro-orbital or facial pain was reported in 28 patients (20.9%); however, these presenting symptoms were common individually (51.5%, 48.5%, and 64.2%, respectively). Hearing loss (35.8%), facial weakness (17.9%), and vertigo (7.5%) were also reported.The most frequently cultured pathogen was Pseudomonas (34.2%), followed by Streptococcus and Staphylococcus. All 134 patients underwent imaging, with computed tomography being the most frequently used modality (56.0%). Nearly all patients received antibiotic therapy (95.6%), with 91 (67.9%) undergoing surgery ranging from myringotomy (26.9%) to petrosectomy (25.4%). Five patients (5.7%) died because of complications related to PA. Mean follow-up was 11.0 months. CONCLUSIONS Petrous apicitis has a variable presentation with potential for severe morbidity. Mortality rates are low, and presentation with Gradenigo's triad is uncommon. Appropriate medical management with surgical drainage can avoid long-term sequelae.
Collapse
|
3
|
Quesada J, Kong A, Tweddle E. An unusual case of acute otitis media resulting in Gradenigo syndrome: CT and MRI findings. Radiol Case Rep 2021; 16:3903-3907. [PMID: 34703515 PMCID: PMC8523869 DOI: 10.1016/j.radcr.2021.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/08/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
With the widespread use of antibiotics, Gradenigo syndrome is a rare complication of acute otitis media (AOM) and acute mastoiditis. It is an uncommon form of petrous apicitis and can be life-threatening. We report the case of a 14-year-old female with unresolved AOM, who developed otorrhea, ipsilateral headaches, diplopia and raised inflammatory markers. Magnetic Resonance Imaging (MRI) demonstrated features of petrous apicitis and confirmed the suspicion of Gradenigo syndrome. The objective of this clinical case report is to highlight this unusual syndrome together with its radiological appearance to improve its diagnosis and management.
Collapse
Affiliation(s)
- Juan Quesada
- Radiology Department, Albury Wodonga Health, 201 Borella Rd, East Albury, NSW 2640, Australia
| | - Andrew Kong
- Radiology Department, Albury Wodonga Health, 201 Borella Rd, East Albury, NSW 2640, Australia
| | - Eliza Tweddle
- Otolaringology, Head and Neck Surgery Department, Albury Wodonga Health, 201 Borella Rd, East Albury, NSW 2640, Australia
| |
Collapse
|
4
|
Danieli L, Montali M, Remonda L, Killer HE, Colosimo C, Cianfoni A. Clinically Directed Neuroimaging of Ophthalmoplegia. Clin Neuroradiol 2017; 28:3-16. [PMID: 29149358 DOI: 10.1007/s00062-017-0646-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Ophthalmoplegia (OP) can have numerous etiologies and different clinical presentations. Most causes of OP can be narrowed down to specific anatomical locations based on clinical information. The aim of this study was to outline the different categories of diseases encountered in patients with OP, based on the location along the ocular motor pathways, and the most appropriate imaging modality for the given scenarios. METHODS Representative neuroimaging examples of pathological processes causing OP are displayed, sequenced by anatomical location and disease category. Correlations between the clinical presentation and site of pathology with imaging protocol recommendations are also presented. RESULTS Diseases affecting ocular movement can be divided into categories including: injuries or diseases of the cerebral hemispheres, midbrain, pons, and cerebellum, ocular motor nerve palsies, intrinsic extraocular muscle diseases and orbital diseases secondarily affecting the extraocular muscles. The cranial nerves responsible for ocular movements can be affected intrinsically or extrinsically along their nuclei, their course in the brainstem, in the cisterns, skull base, cavernous sinuses and orbits. The extraocular muscles can be affected primarily or secondarily by adjacent pathological processes in the orbit. Clinical information can help narrow down the differential diagnoses in terms of anatomical site of involvement and prompt the most appropriate neuroimaging techniques. CONCLUSION By understanding the pathophysiology of OP the neuroradiologist can discuss clinical cases with the referring clinician and determine a timely, accurate method of imaging to achieve the most precise differential diagnosis.
Collapse
Affiliation(s)
- Lucia Danieli
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Via Tesserete 46, 6900, Lugano, Switzerland.
| | - Margherita Montali
- Department of Ophthalmology, Kantonsspital Aarau, Tellstraße 25, 5001, Aarau, Switzerland
- Department of Neuroradiology, Kantonsspital Aarau, Tellstraße 25, 5001, Aarau, Switzerland
| | - Luca Remonda
- Department of Neuroradiology, Kantonsspital Aarau, Tellstraße 25, 5001, Aarau, Switzerland
| | - Hanspeter E Killer
- Department of Ophthalmology, Kantonsspital Aarau, Tellstraße 25, 5001, Aarau, Switzerland
| | - Cesare Colosimo
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Alessandro Cianfoni
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Via Tesserete 46, 6900, Lugano, Switzerland
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstraße 10, 3010, Bern, Switzerland
| |
Collapse
|
5
|
Radhakrishnan R, Son HJ, Koch BL. Petrous apex lesions in the pediatric population. Pediatr Radiol 2014; 44:325-39; quiz 323-4. [PMID: 24584333 DOI: 10.1007/s00247-013-2836-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 10/17/2013] [Accepted: 10/31/2013] [Indexed: 11/30/2022]
Abstract
A variety of abnormal imaging findings of the petrous apex are encountered in children. Many petrous apex lesions are identified incidentally while images of the brain or head and neck are being obtained for indications unrelated to the temporal bone. Differential considerations of petrous apex lesions in children include "leave me alone" lesions, infectious or inflammatory lesions, fibro-osseous lesions, neoplasms and neoplasm-like lesions, as well as a few rare miscellaneous conditions. Some lesions are similar to those encountered in adults, and some are unique to children. Langerhans cell histiocytosis (LCH) and primary and metastatic pediatric malignancies such as neuroblastoma, rhabomyosarcoma and Ewing sarcoma are more likely to be encountered in children. Lesions such as petrous apex cholesterol granuloma, cholesteatoma and chondrosarcoma are more common in adults and are rarely a diagnostic consideration in children. We present a comprehensive pictorial review of CT and MRI appearances of pediatric petrous apex lesions.
Collapse
Affiliation(s)
- Rupa Radhakrishnan
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA,
| | | | | |
Collapse
|
6
|
Jacobsen CL, Bruhn MA, Yavarian Y, Gaihede ML. Mastoiditis and Gradenigo's Syndrome with anaerobic bacteria. BMC EAR, NOSE, AND THROAT DISORDERS 2012; 12:10. [PMID: 22978305 PMCID: PMC3503843 DOI: 10.1186/1472-6815-12-10] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 08/15/2012] [Indexed: 11/10/2022]
Abstract
UNLABELLED BACKGROUND Gradenigo's syndrome is a rare disease, which is characterized by the triad of the following conditions: suppurative otitis media, pain in the distribution of the first and the second division of trigeminal nerve, and abducens nerve palsy. The full triad may often not be present, but can develop if the condition is not treated correctly. CASE PRESENTATION We report a case of a 3-year-old girl, who presented with fever and left-sided acute otitis media. She developed acute mastoiditis, which was initially treated by intravenous antibiotics, ventilation tube insertion and cortical mastoidectomy. After 6 days the clinical picture was complicated by development of left-sided abducens palsy. MRI-scanning showed osteomyelitis within the petro-mastoid complex, and a hyper intense signal of the adjacent meninges. Microbiological investigations showed Staphylococcus aureus and Fusobacterium necrophorum. She was treated successfully with intravenous broad-spectrum antibiotic therapy with anaerobic coverage. After 8 weeks of follow-up there was no sign of recurrent infection or abducens palsy. CONCLUSION Gradenigo's syndrome is a rare, but life-threatening complication to middle ear infection. It is most commonly caused by aerobic microorganisms, but anaerobic microorganisms may also be found why anaerobic coverage should be considered when determining the antibiotic treatment.
Collapse
Affiliation(s)
- Chris Ladefoged Jacobsen
- Department of Otolaryngology, Head and Neck Surgery, Aalborg Hospital - Aarhus University Hospital, Aalborg, Denmark.
| | | | | | | |
Collapse
|
7
|
Aihara M. Continuous facial pain after hitting the face: diagnostic pitfall. THE JOURNAL OF TRAUMA 2011; 71:E100. [PMID: 21986766 DOI: 10.1097/ta.0b013e31822148da] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Masaki Aihara
- Department of Plastic and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.
| |
Collapse
|
8
|
Rossor TE, Anderson YC, Steventon NB, Voss LM. Conservative management of Gradenigo's syndrome in a child. BMJ Case Rep 2011; 2011:2011/apr19_1/bcr0320113978. [PMID: 22696630 DOI: 10.1136/bcr.03.2011.3978] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Gradenigo's syndrome, the triad of suppurative otitis media, abducens nerve palsy and pain in the ophthalmic division of the trigeminal nerve, remains a rare complication of otitis media. A case in a paediatric patient is described, successfully managed conservatively. There is little evidence to support increased use of antibiotics in acute otitis media to prevent this complication.
Collapse
Affiliation(s)
- Thomas E Rossor
- Department of Paediatrics, King's College Hospital, London, UK.
| | | | | | | |
Collapse
|
9
|
Kantas I, Papadopoulou A, Balatsouras DG, Aspris A, Marangos N. Therapeutic approach to Gradenigo's syndrome: a case report. J Med Case Rep 2010; 4:151. [PMID: 20497577 PMCID: PMC2886080 DOI: 10.1186/1752-1947-4-151] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 05/24/2010] [Indexed: 11/10/2022] Open
Abstract
Introduction Traditional management of Gradenigo's syndrome requires aggressive and radical surgery without any attempt to preserve hearing. Recent reports, however, describe a successful outcome after conservative surgical intervention without labyrinthectomy. A similar outcome has also been reported in patients who were only prescribed with antibiotics and did not undergo myringotomy. Case presentation We report the case of a 24-year-old Caucasian Greek woman with Gradenigo's syndrome who was treated by draining her petrous apex via an infralabyrithine approach between her posterior semicircular canal and the jugular bulb. Her inner ear was not sacrificed during the procedure. She presented pre-operatively with ipsilateral conductive hearing loss, which recovered completely four weeks after the surgery. Conclusions Patients with Gradenigo's syndrome may be successfully treated with a combination of long-term permanent drainage and ventilation of the apical cells with corresponding hearing preservation. This can be achieved via a combination of transmastoid, infralabyrinthine and suprajugular approaches, if such would be allowed by the anatomy of the region or if there is enough space between the posterior semicircular canal and the jugular bulb.
Collapse
Affiliation(s)
- Ilias Kantas
- Department of Otolaryngology, Tzanion General Hospital, Piraeus, Greece.
| | | | | | | | | |
Collapse
|
10
|
Abstract
Lesions arising within the temporal bone, where audition and balance receptors are located, are multiple. Beginning with a short clinical and technical overview, this presentation aims to review the most common temporal bone lesions, according to their location. Tumors and malignant otitis externa are the most common lesions of the external auditory canal. MRI features of cholesteatoma redux, transtegmental masses, and paragangliomas are described in the middle ear MRI study. The diagnosis of petrous apex abnormalities is emphasized: cholesterol granuloma, malignant tumor, epidermoid cyst, cholesteatoma, and petrositis. The diagnostic value of CT scan associated with MRI is stressed. This study also includes the main aspects of facial nerve lesions and vascular abnormalities of the area on MRI. The conclusion summarizes the main indications of temporal bone MRI.
Collapse
Affiliation(s)
- F Héran
- Service d'Imagerie et d'ORL, France.
| | | | | |
Collapse
|
11
|
Lee YH, Lee NJ, Kim JH, Song JJ. CT, MRI and gallium SPECT in the diagnosis and treatment of petrous apicitis presenting as multiple cranial neuropathies. Br J Radiol 2005; 78:948-51. [PMID: 16177020 DOI: 10.1259/bjr/71475327] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We present a rare case of petrous apicitis initiated by middle ear inflammation in a diabetic patient with multiple cranial neuropathies for early diagnosis of this potentially life-threatening condition. The lesion appeared as opacification of middle ear, petrous apex with aggressive bony destruction on CT and diffuse petrosal T(1) hypointensity with adjacent soft tissue propagation on MRI. Gallium-67 single-photon emission computed tomography (SPECT) scan also contributed to evaluate response to therapy.
Collapse
Affiliation(s)
- Y H Lee
- Department of Radiology, Head and Neck Surgery, Korea University College of Medicine, Seoul
| | | | | | | |
Collapse
|
12
|
Finkelstein Y, Marcus N, Mosseri R, Bar-Sever Z, Garty BZ. Streptococcus acidominimus infection in a child causing Gradenigo syndrome. Int J Pediatr Otorhinolaryngol 2003; 67:815-7. [PMID: 12791460 DOI: 10.1016/s0165-5876(03)00088-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Gradenigo syndrome is a rare presentation of acute petrositis. The clinical triad of Gradenigo syndrome consists of acute suppurative otitis media, severe unilateral headache and abducens nerve palsy. We report the first case of Gradenigo syndrome caused by Streptococcus acidominimus, a Gram-positive coccus of the Streptococcus viridans group, which rarely causes deep-seated infection in humans. CONCLUSION Gradenigo syndrome may complicate acute otitis media and should be suspected in case of unilateral headache and abducens nerve palsy. Conservative medical treatment without surgery may be considered in some patients.
Collapse
Affiliation(s)
- Y Finkelstein
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah Tiqva 49202, Israel.
| | | | | | | | | |
Collapse
|
13
|
Vazquez E, Castellote A, Piqueras J, Mauleon S, Creixell S, Pumarola F, Figueras C, Carreño JC, Lucaya J. Imaging of complications of acute mastoiditis in children. Radiographics 2003; 23:359-72. [PMID: 12640152 DOI: 10.1148/rg.232025076] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute mastoiditis is a serious complication of acute otitis media in children. Suppurative disease in the mastoid region occasionally spreads to the adjacent dura mater of the posterior and middle cranial fossae and the sigmoid sinus by means of thrombophlebitis, osseous erosion, or anatomic pathways, producing intracranial complications. Computed tomography (CT) should be performed early in the course of the disease to classify the mastoiditis as incipient or coalescent and to detect intracranial complications. On the basis of the clinical features and imaging findings, the disease is managed conservatively with intravenously administered antibiotics or treated with mastoidectomy and drainage plus antibiotic therapy. CT is therefore a decisive diagnostic tool in determining the type of therapy. In addition, magnetic resonance imaging is performed in patients with clinical symptoms or CT findings suggestive of intracranial complications because of its higher sensitivity for detection of extraaxial fluid collections and associated vascular problems.
Collapse
Affiliation(s)
- Elida Vazquez
- Department of Pediatric Radiology, Area Materno-infantil, Hospital Universitario Vall d'Hebron, Psg Vall d'Hebron 119-129, E-08035 Barcelona, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
Gradenigo's syndrome, which is characterised by the triad of suppurative otitis media, pain in the distribution of the trigeminal nerve, and abducens nerve palsy may give rise to potentially fatal complications. Knowledge of the aetiology and appropriate investigations can lead to early diagnosis. A case is reported which illustrates this.
Collapse
Affiliation(s)
- M Motamed
- Department of Otolaryngology, Head and Neck Surgery, Whipps Cross Hospital, London, UK
| | | |
Collapse
|