Middle ear infection and sixth nerve palsy

The changing face of petrous apicitis-a 40-year experience

OBJECTIVES/HYPOTHESIS

Petrous apicitis (PA) is a rare complication of otitis media. Gradenigo syndrome, with the classic triad of otitis, deep pain, and abducens paralysis, is rarer still. The objective of this study was to determine if clinical presentation and management has changed over time.

STUDY DESIGN

Retrospective chart review.

METHODS

Forty-four patients with PA over a 40-year period were studied. Symptoms, signs, and management outcomes were studied. Historical review, surgical anatomy and approaches, pathology, and microbiology, and an illustrative case are included as appendices.

RESULTS

The classical Gradenigo triad of retro-orbital pain, otitis, and abducens palsy occurred in only six of 44 patients (13.6%). Over the 40-year observation period, those needing surgery has decreased.

CONCLUSIONS

Antibiotics remain the primary treatment modality. Surgery is reserved for cases failing to respond to antibiotics. One of the 44 patients in this series died of his disease. Diagnosis and management algorithms based on these observations are suggested.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:195-201, 2018.

Gradenigo's syndrome secondary to chronic otitis media on a background of previous radical mastoidectomy: a case report

INTRODUCTION

Gradenigo's syndrome is nowadays a rare condition characterized by a triad of otorrhea, facial pain with trigeminal nerve involvement and abducens nerve palsy. Most cases are caused by medial extension of acute otitis media into a pneumatized petrous apex and surgical drainage is usually the treatment of choice. We present a case highlighting the pathological mechanism of this disease, demonstrate rare radiological findings associated with this patient, and showcase successful medical treatment without surgical intervention.

CASE PRESENTATION

A 63-year-old Thai man presented with complete Gradenigo triad as a complication of chronic otomastoiditis in spite of clinical history of previous radical mastoidectomy and a nonpneumatization of the petrous apex. Magnetic resonance imaging showed abnormal prominent enhancement at the roof of his right temporal bone, and the dura overlying the floor of right middle cranial fossa and right cavernous sinus. Magnetic resonance imaging also detected right petrous apicitis. With the use of intravenous antibiotics and topical antibiotic eardrops, recovery was observed within 5 days with complete resolution within 2 months.

CONCLUSIONS

Although there is little evidence to support the use of medical therapy in the treatment of Gradenigo's syndrome resulting from chronic ear disease, we here demonstrate successful conservative treatment of Gradenigo's syndrome following chronic otitis media in a patient who underwent previous radical mastoidectomy.

Abducens nerve palsy complicated by inferior petrosal sinus septic thrombosis due to mastoiditis

We present a very rare case of a 29-month-old boy with acute onset right abducens nerve palsy complicated by inferior petrosal sinus septic thrombosis due to mastoiditis without petrous apicitis. Four months after mastoidectomy, the patient fully recovered from an esotropia of 30 prism diopters and an abduction limitation (-4) in his right eye.

Conservative management of Gradenigo's syndrome in a child

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.

Gradenigo-Syndrom

Intracranial complications of acute otitis media are rare in the time of a specific antibiotic therapy. We report about the case of a 13-year-old female patient with an incompletely cured otitis media which was followed by a petrous apicitis presenting abducens nerve palsy. She was successfully treated by a combination of surgical intervention, high dose intravenous antibiotics, systemic corticoid-therapy and hyperbaric oxygen therapy.

Meningovenous structures of the petroclival region: clinical importance for surgery and intravascular surgery

OBJECTIVE

The goals of this investigation were to perform a detailed analysis of petroclival microanatomic features, to investigate the course of the abducens nerve in the petroclival region, and to identify potential causes of injury to neurovascular structures when anterior transpetrosal or transvenous endovascular approaches are used to treat pathological lesions in the petroclival region.

METHODS

Petroclival microanatomic features were studied bilaterally in seven cadaveric head specimens, which were injected with colored silicone before microdissection. Another cadaveric head was used for histological section analyses.

RESULTS

A lateral or medial location of the abducens nerve dural entrance porus, relative to the midline, was correlated with the course and angulation of the abducens nerve in the petroclival region. The angulation of the abducens nerve was greater and the nerve was closer to the petrous ridge in the lateral type, compared with the medial type. The abducens nerve exhibited three changes in direction, which represented the angulations in the petroclival region, at the dural entrance porus, the petrous apex, and the lateral wall of the internal carotid artery. The abducens nerve was covered by the dural sleeve and the arachnoid membrane, which became attenuated between the second and third angulation points. The abducens nerve was anastomosed with the sympathetic plexus and fixed by connective tissue extensions to the lateral wall of the internal carotid artery and the medial wall of Meckel's cave at the third angulation point. There were two types of trabeculations inside the sinuses around the petroclival region (tough and delicate).

CONCLUSION

The petroclival part of the abducens nerve was protected in a dural sleeve accompanied by the arachnoid membrane. Therefore, the risk of abducens nerve injury during petrous apex resection via the anterior transpetrosal approach, with the use of the transvenous route through the inferior petrosal sinus to the cavernous sinus, should be lower than expected. The presence of two anatomic variations in the course of the abducens nerve, in addition to findings regarding nerve angulation and tethering points, may explain the relationships between adjacent structures and the susceptibility to nerve injury with either surgical or endovascular approaches. Venous anatomic variations may account for previously reported cases of subarachnoid hemorrhage with the endovascular approach.

ENT pathology and diplopia

ENT pathology causes diplopia in a minority of patients. Because the various ENT conditions that can produce diplopia are relatively unusual they often escape early detection. We describe the various ENT disorders that can produce diplopia and illustrate this with our experience between 1992 and 1998. We wish to emphasise the benefit which can be obtained from undertaking an ENT history and examination in arriving at the correct diagnosis.