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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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Ali Z, Alhantoosh S, Albaqal Z, Alkhudaimi R, Alharbi AS, Hamad TA. Gradenigo Syndrome: A Case Report of a Rare Complication of Otitis Media. Cureus 2024; 16:e51865. [PMID: 38327941 PMCID: PMC10848083 DOI: 10.7759/cureus.51865] [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: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Otitis media, a common inflammation of the middle ear, frequently complicates upper respiratory infections. Gradenigo's syndrome, a rare complication, manifests as suppurative otitis media, abducens nerve palsy, and severe trigeminal nerve pain. Prompt recognition is vital because of the proximity of the infection to critical neurovascular structures. We present the case of a 38-year-old female who presented with facial pain, otalgia, and diplopia following an upper respiratory infection. Examination revealed facial weakness and abducens nerve palsy. Laboratory results showed elevated inflammatory markers. Imaging confirmed middle ear involvement. Antibiotics were initiated, and myringotomy was performed, resulting in a successful outcome. This case report contributes to understanding Gradenigo's syndrome's clinical nuances, emphasizing the necessity of a structured diagnostic and therapeutic approach. Ongoing research is crucial for refining diagnostic criteria, optimizing treatment, and enhancing pathophysiological understanding. Increased medical education is imperative to ensure early detection and improved patient outcomes.
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Affiliation(s)
- Zainab Ali
- General Practice, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Sajdah Alhantoosh
- General Practice, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Zaynab Albaqal
- General Practice, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Rawan Alkhudaimi
- General Practice, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Tareq A Hamad
- Otolaryngology, Al-Adwani General Hospital, Taif, SAU
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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.
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Seeds A, Coleman SL, Strul S. Gradenigo Syndrome: Mimicker of Slipped Muscle and Shunt Failure. J Neuroophthalmol 2022; 42:e410-e411. [PMID: 34310461 DOI: 10.1097/wno.0000000000001311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Anais Seeds
- Department of Ophthalmology and Visual Sciences, University of Minnesota, Minneapolis, Minnesota
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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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Gradenigo's Syndrome and Bacterial Meningitis in a Patient with a Petrous Apex Cholesterol Granuloma. Case Rep Infect Dis 2020; 2020:8822053. [PMID: 33133707 PMCID: PMC7593741 DOI: 10.1155/2020/8822053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 10/08/2020] [Indexed: 11/18/2022] Open
Abstract
Gradenigo's syndrome (GS) classically involves a triad of ear pain due to acute or chronic otitis media (OM), facial or retro-orbital pain in the distribution of the trigeminal nerve, and an abducens nerve palsy. The simultaneous presentation of all three components has become less common in cases of GS reported in the literature, particularly in the era of antibiotics effective against typical organisms attributed to OM and petrous apicitis. In addition to infectious petrous apicitis arising directly from OM, more recent cases of GS are attributed to the compression of the same traversing cranial nerves in the presence of various expansile petrous apex (PA) lesions, both benign and malignant. We report a case of a 24-year-old male who presented initially with nausea, fever, photophobia, left-sided retro-orbital pain, and headache. He was diagnosed with bacterial meningitis by lumbar puncture and treated with empiric antibiotics, with CSF eventually revealing nontypeable Haemophilus influenzae. Several days into his course, he developed diplopia with leftward gaze. Brain imaging revealed an expansile, erosive PA cholesterol granuloma with associated contiguous dural and leptomeningeal enhancement. The patient improved with antibiotics and eventually underwent surgical intervention. This atypical presentation of GS with a rare complication of meningitis in the setting of a PA granuloma demonstrates the importance of early recognition of this syndrome, as well as consideration of added surgical intervention in patients with pre-existing petrous lesions at potentially higher risk of dangerous complications of GS.
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Vu VN, Savino PJ, Robbins SL. Bilateral abducens nerve palsy due to septic thrombophlebitis. Am J Ophthalmol Case Rep 2019; 16:100566. [PMID: 31737802 PMCID: PMC6849129 DOI: 10.1016/j.ajoc.2019.100566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/03/2019] [Accepted: 10/27/2019] [Indexed: 12/30/2022] Open
Abstract
Purpose To report a case of septic thrombophlebitis producing bilateral abducens nerve palsy. Observation A 65 year-old woman with recent sinus surgery experienced the onset of horizontal diplopia during treatment for bacteremia. Computer tomography of head and a neck ultrasonography showed right internal jugular vein occlusion. Ophthalmology examination was consistent with bilateral abducens nerve palsy. She was treated with systemic antibiotics and antiplatelet therapy with resolution of the internal jugular vein occlusion. The diplopia improved over a six-months. Conclusion and importance Our patient had Lemierre syndrome with an unusual presentation. The patient was treated for septic thrombophlebitis with a resolution of her ocular symptoms.
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Affiliation(s)
- Vincent N Vu
- Ratner Children's Eye Center at the University of California San Diego, 9415 Campus Point Drive, La Jolla, CA, USA
| | - Peter J Savino
- Ratner Children's Eye Center at the University of California San Diego, 9415 Campus Point Drive, La Jolla, CA, USA.,The Neuro-ophthalmology Service, The Shiley Eye Institute, University of California, 9415 Campus Point Drive, La Jolla, CA, USA
| | - Shira L Robbins
- Ratner Children's Eye Center at the University of California San Diego, 9415 Campus Point Drive, La Jolla, CA, USA
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Özkaçmaz S. Acute otitis media associated with Gradenigo syndrome and transverse sinus thrombosis: a case report. J Int Med Res 2019; 47:1348-1352. [PMID: 30669916 PMCID: PMC6421389 DOI: 10.1177/0300060518823404] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Gradenigo syndrome is associated with middle ear infection that extends to the petrous apex, leading to pain at the innervation site of the ophthalmic and maxillary branches of the trigeminal nerve and the development of abducens nerve palsy. Cerebral venous sinus thrombosis is a serious neurological complication of otitis media and occurs secondary to spread of the infection to the underlying bone. We herein report a pediatric case of otitis media associated with Gradenigo syndrome and ipsilateral sigmoid-transverse sinus thrombosis with magnetic resonance imaging findings.
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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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Taklalsingh N, Falcone F, Velayudhan V. Gradenigo's Syndrome in a Patient with Chronic Suppurative Otitis Media, Petrous Apicitis, and Meningitis. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1039-1043. [PMID: 28955030 PMCID: PMC5629926 DOI: 10.12659/ajcr.904648] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Patient: Male, 58 Final Diagnosis: Bacterial meningitis Symptoms: Altered mental status • headache • neck stiffness • vomiting Medication: — Clinical Procedure: — Specialty: Infectious Diseases
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Affiliation(s)
- Nicholas Taklalsingh
- Department of Internal Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Franco Falcone
- Department of Internal Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
| | - Vinodkumar Velayudhan
- Department of Radiology, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
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Jensen PVF, Avnstorp MB, Dzongodza T, Chidziva C, von Buchwald C. A fatal case of Gradenigo's syndrome in Zimbabwe and the Danish-Zimbabwean ENT collaboration. Int J Pediatr Otorhinolaryngol 2017; 97:181-184. [PMID: 28483232 DOI: 10.1016/j.ijporl.2017.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
As a part of a bilateral educational exchange program two Danish ENT residents were invited to Zimbabwe in 2015. During this exchange a 9-year-old girl was admitted due to complications to acute otitis media (AOM). She developed Gradenigo's syndrome and later on a brain abscess leading to a fatal outcome. Life threatening complications to AOM are rare in developed countries today but are still a challenge in developing countries. We put forward this case from a developing country to bring focus to the fact that a fatal outcome is the consequence if specialist treatment is not accessible.
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Affiliation(s)
- P V F Jensen
- Dept. of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark.
| | - M B Avnstorp
- Dept. of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - T Dzongodza
- Dept. of Otorhinolaryngology, Parirenyatwa Hospital, Mazove Street, Harare, Zimbabwe
| | - C Chidziva
- Dept. of Otorhinolaryngology, Parirenyatwa Hospital, Mazove Street, Harare, Zimbabwe
| | - C von Buchwald
- Dept. of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
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Kazemi T. Acute Otitis Media-Induced Gradenigo Syndrome, a Dramatic Response to Intravenous Antibiotic. IRANIAN JOURNAL OF OTORHINOLARYNGOLOGY 2017; 29:165-169. [PMID: 28589111 PMCID: PMC5448032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Petrositis is a rare but severe complication of acute otitis media and mastoiditis. Despite efficient antibiotic therapy, there are still reports of both intratemporal and intracranial complications of otitis media with the potential risk of high morbidity and mortality. Petrositis has traditionally been treated with surgery, but recent advances in imaging, with improved antibiotic treatment, allow more conservative management. CASE REPORT In this case report we describe the clinical course and treatment of a 33-year-old man with petrous apicitis who presented with severe otalgia, retro-orbital pain, and sixth cranial nerve palsy Gradenigo syndrome. Our patient showed a dramatic response to intravenous antibiotics only, without need for any surgical intervention, even myringotomy. CONCLUSION It seems that early detection and management of this syndrome before development of other intratemporal or intracranial complications may prevent the need for surgical intervention.
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Fonte purulente de la cornée : une complication inattendue de l’otite moyenne aiguë. Arch Pediatr 2016; 23:823-6. [DOI: 10.1016/j.arcped.2016.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/16/2015] [Accepted: 05/11/2016] [Indexed: 11/17/2022]
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Jensen PVF, Hansen MS, Møller MN, Saunte JP. The Forgotten Syndrome? Four Cases of Gradenigo’s Syndrome and a Review of the Literature. Strabismus 2016; 24:21-7. [DOI: 10.3109/09273972.2015.1130067] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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