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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
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Mammarella F, Loperfido A, Velletrani G, Casorati F, Stasolla A, Di Girolamo S, Bellocchi G. Refractory Pseudomonas Osteomyelitis of the Skull Base With Gradenigo's Syndrome: Early Dysphagia and Late Abducens Nerve Palsy. J Med Cases 2024; 15:43-48. [PMID: 38646423 PMCID: PMC11027766 DOI: 10.14740/jmc4191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Gradenigo's syndrome (GS) is a rare entity characterized by otitis media, pain in the trigeminal nerve distribution and abducens nerve palsy. The classic triad is uncommon, making the diagnostic workup challenging. Specifically, the diagnostic approach includes medical history, a complete otorhinolaryngological examination, a pure-tone audiogram and radiological investigation such as contrast-enhanced computed tomography scan and magnetic resonance imaging of head and neck. Broad-spectrum antibiotics are the first-line treatment, such as intravenous (IV) ceftriaxone and IV metronidazole. Here, we present the case of a 71-year-old man with a previous history of otitis media and poorly controlled type 2 diabetes mellitus. He presented to our attention with facial pain, left hemilarynx paralysis, dysphagia and otorrhea. The patient was treated with broad-spectrum antibiotics without any clinical improvement. Imaging evaluations demonstrated the presence of wide and poorly defined pathological material with epicenter in the masticatory space, involving all nearby structures. The patient underwent multiple biopsies without obtaining a definitive tissue diagnosis of neoplasia. After 2 months, the patient developed delayed VI cranial nerve palsy, providing evidence of GS. Although incomplete, GS has been described in the literature; however, none of the cases exhibited a latent abducent deficit. To the best of our knowledge, this is the only case with a delayed onset of abducens nerve palsy.
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Affiliation(s)
- Fulvio Mammarella
- Department of Otorhinolaryngology, San Camillo Forlanini Hospital, 00152 Rome, Italy
| | - Antonella Loperfido
- Department of Otorhinolaryngology, San Camillo Forlanini Hospital, 00152 Rome, Italy
| | - Gianluca Velletrani
- Department of Otorhinolaryngology, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Francesco Casorati
- Department of Otorhinolaryngology, San Camillo Forlanini Hospital, 00152 Rome, Italy
| | - Alessandro Stasolla
- Department of Neuroradiology, San Camillo Forlanini Hospital, 00152 Rome, Italy
| | - Stefano Di Girolamo
- Department of Otorhinolaryngology, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Gianluca Bellocchi
- Department of Otorhinolaryngology, San Camillo Forlanini Hospital, 00152 Rome, Italy
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Ibrahim Z, Fox-Lewis S, Correia JA. Fusobacterium necrophorum an Underrecognized Cause of Petrous Apicitis Presenting with Gradenigo Syndrome: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e942652. [PMID: 38319911 PMCID: PMC10862527 DOI: 10.12659/ajcr.942652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/28/2023] [Accepted: 12/19/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more uncommon is Gradenigo syndrome (GS), a result of PA, characterized by a triad of otitis media or purulent otorrhea, pain within the regions innervated by the first and second division of the trigeminal nerve, and ipsilateral abducens nerve palsy. Recent literature has demonstrated increasing reports of Fusobacterium necrophorum isolated in cases of GS. CASE REPORT A 21-year-old man presented with otalgia, reduced hearing, and severe headache. Examination revealed right-sided purulent otorrhea, anesthesia within the trigeminal nerve distribution, and an ipsilateral abducens nerve palsy. F. necrophorum was isolated from an ear swab and a blood culture. Computed tomography and magnetic resonance imaging (MRI) demonstrated otomastoiditis, PA, cavernous sinus thrombosis, and severe stenosis of the petrous internal carotid artery. He was treated with intravenous benzylpenicillin, underwent a mastoidectomy and insertion of a ventilation tube, and was started on a 3-month course of dabigatran. Interval MRI showed improved internal carotid artery caliber, persistent petrous apex inflammation, and normal appearance of both cavernous sinuses. Follow-up clinical review noted persistent abducens and trigeminal nerve dysfunction. CONCLUSIONS We identified 190 cases of PA; of these, 80 presented with the classic Gradenigo triad. Fusobacterium sp. were cultured in 10% of GS cases, making them the most frequent isolates. Due to the fastidious nature of F. necrophorum, it may be underrepresented in the historical literature, and we recommend that empiric antibiotics cover anaerobic organisms.
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Affiliation(s)
- Zaid Ibrahim
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Shivani Fox-Lewis
- Department of Microbiology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Jason A. Correia
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
- Neurosurgery Research Unit, The Centre for Brain Research, The University of Auckland, Auckland, New Zealand
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Kloth C, Beck A, Sollmann N, Beer M, Horger M, Thaiss WM. Imaging of Pathologies of the Temporal Bone and Middle Ear: Inflammatory Diseases, Their Mimics and Potential Complications-Pictorial Review. Tomography 2023; 9:2190-2210. [PMID: 38133074 PMCID: PMC10747582 DOI: 10.3390/tomography9060170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
Imaging of the temporal bone and middle ear is challenging for radiologists due to the abundance of distinct anatomical structures and the plethora of possible pathologies. The basis for a precise diagnosis is knowledge of the underlying anatomy as well as the clinical presentation and the individual patient's otological status. In this article, we aimed to summarize the most common inflammatory lesions of the temporal bone and middle ear, describe their specific imaging characteristics, and highlight their differential diagnoses. First, we introduce anatomical and imaging fundamentals. Additionally, a point-to-point comparison of the radiological and histological features of the wide spectrum of inflammatory diseases of the temporal bone and middle ear in context with a review of the current literature and current trends is given.
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Affiliation(s)
- Christopher Kloth
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (N.S.); (M.B.); (W.M.T.)
- Radiology and Radiation Therapy Lindau, Friedrichshafener Str. 83, 88131 Lindau (Lake Constance), Germany
| | - Annika Beck
- Institute of Pathology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany;
| | - Nico Sollmann
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (N.S.); (M.B.); (W.M.T.)
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (N.S.); (M.B.); (W.M.T.)
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany;
| | - Wolfgang Maximilian Thaiss
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (N.S.); (M.B.); (W.M.T.)
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany;
- Department of Nuclear Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Rifai Y, Cassimatis N, Soliman Md I. Neurosurgical Intervention in the Treatment of Gradenigo Syndrome: A Case Report. Cureus 2023; 15:e47573. [PMID: 38022299 PMCID: PMC10666561 DOI: 10.7759/cureus.47573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Gradenigo syndrome comprises a clinical triad: retro-orbital pain, sixth cranial nerve palsy, and purulent otorrhea. This clinical syndrome often arises secondary to petrous apicitis, which is an infection of the petrous apex that may result from the contiguous spread of infection from the ear or mastoid. This syndrome is very rare, and based on the existing literature, the initial approach for treatment involves long-term administration of IV antibiotics, which may resolve the underlying infection related to petrous apicitis, mastoiditis, and/or otitis media. In this case, the patient, a 69-year-old male, had a progression of several symptoms, including recurrent headaches, diplopia, hearing loss, and dysphagia, despite long-term antibiotic therapy and a prior mastoidectomy. Thus, the neurosurgical team decided to intervene via anterior petrous bone resection via the Kawase approach, which unfortunately did not result in the resolution of the patient's symptoms. The patient continued to have symptoms of Gradenigo syndrome, including sixth cranial nerve palsy and was subsequently referred to outpatient follow-up for further management. In this report, we present the patient's case and a brief review of the literature concerning various treatment modalities for Gradenigo syndrome.
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Affiliation(s)
- Yasmine Rifai
- General Surgery, Hackensack University Medical Center, Hackensack, USA
| | | | - Isaac Soliman Md
- Internal Medicine, Hackensack Meridian Health Mountainside Medical Center, Montclair, USA
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Benavente K, Kozai L, Silangcruz K, Banerjee D. The risks of rejection vs. infection: Ramsay Hunt syndrome, Gradenigo syndrome, and varicella meningoencephalitis in a heart transplant patient. Eur Heart J Case Rep 2023; 7:ytad373. [PMID: 37575545 PMCID: PMC10413418 DOI: 10.1093/ehjcr/ytad373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
Background Orthotopic heart transplant (OHT) recipients are at increased risk for varicella zoster reactivation, and severe complications may arise due to their immunosuppressive regimens. Managing immunosuppression in acute infection is difficult, and specific guideline recommendations or evidence from the literature are lacking. However, patient care must involve weighing the risk of transplant rejection with the consequences of worsening infection. Case summary An OHT patient with a history of multiple episodes of acute rejection, latent varicella zoster virus (VZV) infection, and recent completion of anti-viral prophylaxis presented with unilateral facial droop and pain, abducens nerve palsy, crusting facial rash, and ear swelling. Imaging revealed necrotizing otitis externa, with associated otitis media, and petrous apicitis concerning for Gradenigo syndrome. A VZV-positive viral panel confirmed our suspicion for Ramsay Hunt syndrome (RHS). The patient's mentation continued to decline, and subsequent lumbar puncture also revealed VZV meningoencephalitis. The patient's mycophenolate mofetil (MMF) was suspended, with continuation of tacrolimus, and initiation of intravenous acyclovir. The patient demonstrated gradual resolution of his infection, without developing any signs of acute rejection. Discussion Varicella zoster virus reactivation is common in OHT patients, particularly when viral prophylaxis is discontinued; however, cardiologists should be aware of the rarer manifestations that can manifest in these immunocompromised patients. This is the first documented case of simultaneous RHS, Gradenigo syndrome, and VZV meningoencephalitis in any patient, regardless of transplant status. We demonstrate that even in patients at very high risk of rejection, MMF can be safely discontinued and host immunity maintained with temporary tacrolimus monotherapy.
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Affiliation(s)
- Kevin Benavente
- Department of the Internal Medicine Residency Program, University of Hawaii, 1356 Lusitania Street #510, Honolulu, HI 96813, USA
| | - Landon Kozai
- Department of the Internal Medicine Residency Program, University of Hawaii, 1356 Lusitania Street #510, Honolulu, HI 96813, USA
| | - Krixie Silangcruz
- Department of the Internal Medicine Residency Program, University of Hawaii, 1356 Lusitania Street #510, Honolulu, HI 96813, USA
| | - Dipanjan Banerjee
- Department of the Cardiology Fellowship Program, University of Hawaii, 1301 Punchbowl Street, Pauahi 3rd Floor, Queen's Heart, Honolulu, HI 96813, USA
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Gokharman FD, Kocak O, Irgul B, Kosar P, Aydin S. There Is No Relation between Epitympanic Recess Volume and Chronic Otitis Media. Tomography 2023; 9:1332-1340. [PMID: 37489474 PMCID: PMC10366856 DOI: 10.3390/tomography9040106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Chronic otitis media is recurrent infection of the middle ear and mastoid air cells in the setting of perforation of the tympanic membrane. Risk factors for chronic otitis media include predisposing characteristics such as gender, allergies, Eustachian tube dysfunction, history of acute otitis media, and upper respiratory tract infection. The purpose of this study was to evaluate the potential relationship between chronic otitis media and epitympanic recess volume. MATERIALS AND METHODS A total of 197 patients with chronic otitis media had their epitympanic recess volume compared to the epitympanic volume of 99 healthy controls. The epitympanic recess volume was measured via the 3D volumetric measurement tool of the local PACS. Epitympanic recess volume measurement was performed using axial sections in a plane starting from the level of the malleus head-anvil body in the craniocaudal direction to the tegmen tympanum. RESULTS It was shown that patients with bilateral involvement had an epitympanic recess volume of 75.00 mm3, compared to 72.30 mm3 in those with unilateral chronic otitis media. The healthy control group's median value for the epitympanic recess was 74.73 mm3. CONCLUSIONS Epitympanic volume values did not differ substantially between patients with chronic otitis media and healthy persons, and epitympanic volume was not recognized as a predisposing factor (p = 0.686).
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Affiliation(s)
- Fatma Dilek Gokharman
- Department of Radiology, Ankara Training and Research Hospital, Ankara 06660, Turkey
| | - Omer Kocak
- Department of Radiology, Ankara Training and Research Hospital, Ankara 06660, Turkey
| | - Baris Irgul
- Department of Radiology, Erzincan Binali Yidirim University, Erzincan 24100, Turkey
| | - Pinar Kosar
- Department of Radiology, Ankara Training and Research Hospital, Ankara 06660, Turkey
| | - Sonay Aydin
- Department of Radiology, Erzincan Binali Yidirim University, Erzincan 24100, Turkey
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Robinson C, Maraj D, Minhas JS, Bhatia M, Kak V. Gradenigo's Syndrome and Vernet Syndrome as Presenting Signs of Nasopharyngeal Carcinoma. Cureus 2023; 15:e41636. [PMID: 37565094 PMCID: PMC10411312 DOI: 10.7759/cureus.41636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
Both Gradenigo's syndrome and Vernet syndrome are rare pathologies of the intracranial space; both involve compression of a particular anatomic location in the skull, thus affecting structures nearby or within that space. A patient presenting with one or both of these syndromes should raise concern for malignancy, head trauma, or an intracranial infection. We present a case of a 39-year-old female with three weeks of left-sided ear, face, and neck pain along with difficulty swallowing and reduced vision in the left eye. Magnetic resonance imaging of the brain revealed fullness in the left nasopharyngeal region, raising concern for malignancy or infection. Biopsy of the mass ultimately revealed Epstein-Barr virus positive nasopharyngeal carcinoma, nonkeratinizing undifferentiated type, along with culture data revealing methicillin-resistant Staphylococcus aureus positive left otomastoiditis. She received chemoradiation therapy along with six weeks of antibiotic therapy. A patient presenting with symptoms reflective of a sinus infection unrelieved by antibiotics with concomitant cranial nerve deficits should raise clinical concern for an intracranial pathology rather than a simple case of sinusitis.
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Affiliation(s)
- Ciji Robinson
- Internal Medicine, Henry Ford Health System, Jackson, USA
| | - Diva Maraj
- Internal Medicine, Henry Ford Health System, Jackson, USA
| | - Jasdeep S Minhas
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | | | - Vivek Kak
- Infectious Disease, Henry Ford Health System, Jackson, USA
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Chan KC, Chen SL. Diplopia in a Child: Gradenigo Syndrome Is an Unforgettable Disease. EAR, NOSE & THROAT JOURNAL 2023; 102:NP53-NP55. [PMID: 33507110 DOI: 10.1177/0145561321989459] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Gradenigo syndrome is a clinical triad of abducens nerve palsy, retro-orbital pain (trigeminal ganglionitis), and chronic otorrhea (otitis media). The etiology of Gradenigo syndrome results from apical petrositis secondary to suppurative otitis media. Although apical petrositis has gradually become uncommon in modern society due to the widespread use of antibiotics, Gradenigo syndrome should be considered in the differential diagnosis of a child's diplopia.
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Affiliation(s)
- Kai-Chieh Chan
- Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Lung Chen
- Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
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Shree R, Mahesh KV, Balaini N, Goel A. Oculomotor Cranial Neuropathies: Diagnosis and Management. Ann Indian Acad Neurol 2022; 25:S70-S82. [PMID: 36589037 PMCID: PMC9795710 DOI: 10.4103/aian.aian_167_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/02/2022] [Indexed: 01/04/2023] Open
Abstract
Ocular nerve palsies are among the most common cranial neuropathies in neurological practice. Nerves can get affected anywhere along their path from the brainstem to the orbit. There can be isolated involvement of multiple cranial nerves together. The etiologies differ according to the type of presentation. The steps toward the diagnosis need to be strategically planned and must be based on clinical localization. It is crucial to make proper localization to plan further investigations and thus treatment of the etiology. This review covers the approach toward the diagnosis, etiologies involved, and management of ocular cranial neuropathies.
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Affiliation(s)
- Ritu Shree
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India,Address for correspondence: Dr. Ritu Shree, Level-1, Block-A, Room number: 11, Nehru Hospital, PGIMER, Chandigarh - 160 012, India. E-mail:
| | - Karthik Vinay Mahesh
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Neeraj Balaini
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Abeer Goel
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Bano S, Nawaz A, Asmar A, Aemaz Ur Rehman M, Farooq H, Ali H. Gradenigo's syndrome presenting as IX and X cranial nerve palsy without clinically apparent ear infection: A case report and review of literature. eNeurologicalSci 2022; 27:100397. [PMID: 35330846 PMCID: PMC8938864 DOI: 10.1016/j.ensci.2022.100397] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/02/2022] [Accepted: 03/05/2022] [Indexed: 11/05/2022] Open
Abstract
Gradenigo's syndrome (GS) is a triad (otorrhea, abducens nerve palsy, and pain in the trigeminal nerve distribution) of clinical findings that are caused by contiguous spread of petrous apicitis to the nearby neurovascular structures. Petrous apicitis is usually secondary to otitis media but atypical etiologies and absence of the classical triad pose a diagnostic challenge for physicians. We report a rare case of GS in an afebrile 55-year-old male who presented with unilateral headache, dysphagia and hoarseness (IX and X cranial nerve involvement), and diplopia with lateral gaze palsy (VI nerve involvement) in the absence of trigeminal neuralgia or a history of otitis media. Magnetic Resonance Imaging (MRI) revealed hyperintense lesions in the right petrous apex indicating petrous apicitis, the hallmark of GS. Prompt initiation of broad-spectrum antibiotics led to a marked improvement in dysphagia and voice quality on the 4th post-admission day, and complete resolution of symptoms by the end of the fourth week. This shows that GS can present even in the absence of clinically apparent ear infection and cranial nerve palsies may not be limited to the V and VI nerve in all cases. Physicians should be aware of such atypical manifestations as prompt radiological assessment followed by early antibiotics can prevent life-threatening complications from developing. Gradenigo's syndrome is a triad of otorrhea, facial pain and VI nerve palsy. The classic triad is seen in less than half of the cases. Petrous apicitis is the hallmark radiologic finding. The history of ear infection may not always be evident. Presentation with IX and X nerve palsy can pose a diagnostic challenge.
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Bonavia L, Jackson J. Gradenigo Syndrome in a 14-Year-old Girl as a Consequence of Otitis Media With Effusion. J Neuroophthalmol 2022; 42:e408-e409. [PMID: 34001731 PMCID: PMC8834142 DOI: 10.1097/wno.0000000000001278] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Luke Bonavia
- Ballarat Health Services (LB), Ballarat Central, Victoria, Australia; Albury Base Hospital (JJ), Wodonga, Victoria, Australia; and University of NSW Medical School (JJ), Albury Campus, Albury, NSW, Australia
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13
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Dhiman R, Lakra S, Panda PK, Hemachandran N, Sharma S, Saxena R. Neuro-ophthalmic manifestations of tuberculosis. Eye (Lond) 2022; 36:15-28. [PMID: 34127839 PMCID: PMC8727585 DOI: 10.1038/s41433-021-01619-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.
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Affiliation(s)
- Rebika Dhiman
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
| | - Subodh Lakra
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prateek Kumar Panda
- Pediatric Neurology Services, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Naren Hemachandran
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Saxena
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Liu Y, Yeh PK, Lin YP, Sung YF. Steroid-Responsive Gradenigo's Syndrome Mimicking Subdural Hematoma. Cureus 2021; 13:e19547. [PMID: 34917431 PMCID: PMC8668413 DOI: 10.7759/cureus.19547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 01/18/2023] Open
Abstract
Gradenigo's syndrome (GS) is featured by a clinical triad of otorrhea, retro-orbital pain, and a sixth nerve palsy. Clinical examination is crucial prior to considering neuroimaging. The majority of cases are secondary to infection thus requiring long-term broad-spectrum antibiotics; severe cases also require surgical intervention for risk of intracranial abscess or even death. The patient was a 35-year-old female who presented with right temporal headache and right retro-orbital pain. The initial diagnosis from the local clinic was of subdural hemorrhage. Cranial nerve (CN) VI paresis was noted upon examination and inflammatory process was documented based on brain MR. The patient was diagnosed with Gradenigo's syndrome and administered antibiotics and steroids. Symptoms recurred after cessation of steroids and once antibiotics-related fever developed. The symptoms resolved after stopping the antibiotics and reintroducing steroids. The MRI performed after three months recorded no brain inflammation. We report a Gradenigo's syndrome caused by chronic inflammation with good response to steroids. To our best knowledge, there were merely approximately 80 patients who were reported with Gradnigo or Gradenigo's syndrome before. Infection comprised 76% of cases, thus broad-spectrum and long-term antibiotics use have been emphasized instead of steroid use. However, steroids also play an important role in reducing nerve injury by edematous change.
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Affiliation(s)
- Yi Liu
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
| | - Po-Kuan Yeh
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
| | - Yu-Pang Lin
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
| | - Yueh-Feng Sung
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
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Gadoxetate Disodium-Enhanced Imaging of Gradenigo Syndrome in End-Stage Renal Disease. J Neuroophthalmol 2021; 41:e375-e377. [PMID: 33813531 DOI: 10.1097/wno.0000000000001218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT A 65-year-old man with end-stage renal disease on peritoneal dialysis was admitted for new onset binocular double vision, failure to thrive, and debilitating right-sided headaches. Medical history was significant for tympanomastoidectomy for polymicrobial mastoiditis and treatment with IV antibiotics. MRI brain without contrast was read by radiology initially as showing expected postsurgical changes; however, given patient's history of mastoiditis infection, there was a high clinical suspicion for Gradenigo syndrome. MRI brain was repeated with gadoxetate contrast to minimize the risk of nephrogenic systemic fibrosis (NSF) in a patient with severe renal disease and this revealed an intracranial empyema involving both the trigeminal and abducens nerves confirming the diagnosis of Gradenigo syndrome. This case presented a diagnostic challenge because of suboptimal visualization on initial nonenhanced MRI. Gadoxetate was chosen because of its unique properties including high hepatobiliary excretion making it a safer form of gadolinium-based contrast agent that may not have the potential to precipitate NSF.
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Kentab AY, Kentab OY. Facial Neuritis as a Manifestation of Gradenigo's Syndrome. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1730920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractGradenigo's syndrome (GS) is a rare, acquired syndrome caused by middle ear infections or mastoiditis. It is identified by the triad of otorrhea due to otitis media (OM), retro-orbital pain in the region innervated by the first and second divisions of the trigeminal nerve, and diplopia as a result of cranial nerve (CN) VI palsy. As a result of extension of the inflammation, the facial nerve (VII) may also be affected. GS has a poor prognosis unless promptly diagnosed and treated. Herein, we report the clinical and radiological findings observed in two children diagnosed with chronic suppurative OM, mastoiditis, and facial neuritis. Both were medically managed as cases of GS with high-dose intravenous antibiotic and full recovery was achieved a few weeks after discharge. There was no need for any surgical intervention. This report illustrates the importance of early recognition, diagnosis, and treatment of this treatable syndrome using antibiotics to prevent subsequent fatal complications and further need for surgical intervention.
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Affiliation(s)
- Amal Y. Kentab
- Division of Neurology, Department of Paediatric, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Osama Y. Kentab
- Emergency Department, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
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Biart S, Panicker J. Insidious onset of headache, diplopia and Horner's syndrome: a rare case of petrous bone osteomyelitis. BMJ Case Rep 2019; 12:12/9/e231062. [PMID: 31537596 DOI: 10.1136/bcr-2019-231062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present an unusual case of skull base osteomyelitis in an 88-year-old woman. She presented with gradual onset unilateral headache and diplopia. On examination, there was evidence of a left-sided Horner's and ipsilateral sixth nerve palsy. In addition to persistent raised inflammatory markers, an MRI neck identified signal change in the petrous bone confirming a diagnosis of skull base osteomyelitis. Skull base osteomyelitis should be considered in presentations of subacute raised inflammatory markers in the context of ipsilateral cranial nerve signs.
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Affiliation(s)
| | - Janki Panicker
- Diabetes and Endocrine, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
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Mortazavi MM, Khan MA, Quadri SA, Suriya SS, Fahimdanesh KM, Fard SA, Hassanzadeh T, Taqi MA, Grossman H, Tubbs RS. Cranial Osteomyelitis: A Comprehensive Review of Modern Therapies. World Neurosurg 2018; 111:142-153. [DOI: 10.1016/j.wneu.2017.12.066] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/07/2017] [Accepted: 12/09/2017] [Indexed: 11/28/2022]
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Gadre AK, Chole RA. The changing face of petrous apicitis-a 40-year experience. Laryngoscope 2017; 128:195-201. [PMID: 28378370 DOI: 10.1002/lary.26571] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2017] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Arun K Gadre
- Department of Otolaryngology-Head and Neck Surgery, Heuser Hearing Institute, University of Louisville, Louisville, Kentucky, U.S.A.,Department of Surgery, Heuser Hearing Institute, University of Louisville, Louisville, Kentucky, U.S.A
| | - Richard A Chole
- Department of Otolaryngology, Washington University, St. Louis, Missouri, U.S.A
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Abstract
Chronic otitis media (COM) is a common problem facing general practitioners, pediatricians and otolaryngologists. This article reviews the aetiopathogenesis, epidemiology, presentation, natural history, complications and management of COM. The literature was reviewed by using the PubMed search engine and entering a combination of terms including "COM", "diagnosis", "incidence", "complications" and "management". Relevant articles were identified and examined for content. What is the "take-home" message for the clinician? COM is a common problem with various sub-categories according to the disease state. It most commonly presents with painless otorrhoea and hearing loss. Treatment options vary according to the activity and type of disease encountered. COM carries significant patient morbidity.
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Affiliation(s)
- Sebastian Wallis
- Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust , York , UK
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21
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Nair AS, Kumar BV. A patient with acute abducens nerve palsy for lower segment caesarean section. Indian J Anaesth 2014; 58:359-60. [PMID: 25024496 PMCID: PMC4091019 DOI: 10.4103/0019-5049.135095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Abhijit S Nair
- Department of Anesthesia, Yashoda Hospitals, Somajiguda, Hyderabad, Andhra Pradesh, India
| | - B Vijay Kumar
- Department of Anesthesia, Yashoda Hospitals, Somajiguda, Hyderabad, Andhra Pradesh, India
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Gradenigo's syndrome: is fusobacterium different? Two cases and review of the literature. Int J Pediatr Otorhinolaryngol 2014; 78:166-9. [PMID: 24315216 DOI: 10.1016/j.ijporl.2013.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/05/2013] [Accepted: 11/09/2013] [Indexed: 11/21/2022]
Abstract
Gradenigo's syndrome is a rare but life threatening complication of acute otitis media (AOM), which includes a classic triad of otitis media, deep facial pain and ipsilateral abducens nerve paralysis. The incidence of Fusobacterium necrophorum infections has increased in recent years. We describe two cases of Gradenigo's syndrome caused by F. necrophorum. Additional four cases were identified in a review of the literature. Gradenigo's syndrome as well as other neurologic complications should be considered in cases of complicated acute otitis media. F. necrophorum should be empirically treated while awaiting culture results.
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Hegde AN, Mohan S, Pandya A, Shah GV. Imaging in Infections of the Head and Neck. Neuroimaging Clin N Am 2012; 22:727-54. [DOI: 10.1016/j.nic.2012.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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24
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Mohan S, Hoeffner E, Bigelow DC, Loevner LA. Applications of Magnetic Resonance Imaging in Adult Temporal Bone Disorders. Magn Reson Imaging Clin N Am 2012; 20:545-72. [DOI: 10.1016/j.mric.2012.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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25
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Ricks RG, Hollis L. Embryonic rhabdomyosarcoma presenting as Gradenigo's syndrome. BMJ Case Rep 2012; 2012:bcr.08.2011.4723. [PMID: 22665865 DOI: 10.1136/bcr.08.2011.4723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors report a previously undocumented case of parapharyngeal rhabdomyosarcoma presenting as Gradenigo's syndrome and review the history and aetiology of Gradenigo's syndrome. With sensitive diagnostic acumen this rare cause of Gradenigo's like syndrome was identified and correct treatment initiated.
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26
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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.
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Affiliation(s)
- Thomas E Rossor
- Department of Paediatrics, King's College Hospital, London, UK.
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28
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Suppurative intracranial thrombophlebitis. HANDBOOK OF CLINICAL NEUROLOGY 2010. [PMID: 20109678 DOI: 10.1016/s0072-9752(09)96008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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Shim JK, Moon JC, Yoon KB, Kim WO, Yoon DM. Hemifacial Pain Accompanied with Delayed Ipsilateral Abducens Nerve Palsy: Tolosa-Hunt Syndrome -A case report-. Korean J Pain 2006. [DOI: 10.3344/kjp.2006.19.1.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jae Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Cheon Moon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Bong Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- The Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Won Oak Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- The Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duck Mi Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- The Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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