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Wang W, Yao YF. A Rare Case of Abducens Nerve Palsy Caused by Primary Squamous Cell Carcinoma of the Middle Ear. Neuroophthalmology 2024; 48:373-376. [PMID: 39145322 PMCID: PMC11321397 DOI: 10.1080/01658107.2024.2336240] [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: 01/02/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 08/16/2024] Open
Abstract
Abducens nerve palsy is the most common ocular motor nerve palsy, and its possible aetiologies are numerous and diverse. Primary malignancy rarely occurs in the middle ear, with most cases associated with long-standing ear discharge and peak age of presentation in the sixties. We report a rare case of a 64-year-old male who presented with right abducens nerve palsy, which led to the diagnosis of primary squamous cell carcinoma of the right middle ear, and to our knowledge, this has not been reported previously in English literature.
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Affiliation(s)
- Weiwei Wang
- Department of Ophthalmology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory for Corneal Diseases Research of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yu-Feng Yao
- Department of Ophthalmology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory for Corneal Diseases Research of Zhejiang Province, Hangzhou, Zhejiang, China
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2
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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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3
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Schmit C, Runge A, Jöbstl A, Widmann G, Schmutzhard J, Hofauer B. [Sudden-onset double vision-a complication requiring interdisciplinary treatment]. HNO 2024:10.1007/s00106-024-01450-x. [PMID: 38498175 DOI: 10.1007/s00106-024-01450-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/20/2024]
Affiliation(s)
- C Schmit
- Universitätsklinik für Hals‑, Nasen- und Ohrenheilkunde, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - A Runge
- Universitätsklinik für Hals‑, Nasen- und Ohrenheilkunde, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - A Jöbstl
- Universitätsklinik für Radiologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - G Widmann
- Universitätsklinik für Radiologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - J Schmutzhard
- Universitätsklinik für Hals‑, Nasen- und Ohrenheilkunde, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - B Hofauer
- Universitätsklinik für Hals‑, Nasen- und Ohrenheilkunde, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
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4
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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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Guarnizo A, Rugilo C. Gradenigo's syndrome associated to internal carotid artery vasculitis. Acta Neurol Belg 2023:10.1007/s13760-023-02408-6. [PMID: 37945802 DOI: 10.1007/s13760-023-02408-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Angela Guarnizo
- Department of Radiology, Division of Neuroradiology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 # 117-15, Bogotá, Colombia.
| | - Carlos Rugilo
- Department of Radiology, Division of Neuroradiology, Hospital de Pediatría J. P. Garrahan, Combate de los Pozos 1881, (C 1245 AAM), Buenos Aires, Argentina
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Branco T, Marques C, Santos VC, Lopes JM. Gradenigo's Syndrome With Septic Lateral Sinus Thrombosis. Cureus 2023; 15:e34797. [PMID: 36915831 PMCID: PMC10007907 DOI: 10.7759/cureus.34797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/11/2023] Open
Abstract
Gradenigo's syndrome (GS) is a rare but life-threatening complication of acute otitis media (AOM). It is classically defined as a clinical triad of acute otitis media, ipsilateral sixth (abducens) nerve palsy, and pain in the distribution of the first and second branches of the trigeminal nerve. Another rare but serious complication of AOM is venous sinus thrombosis, which is often associated with GS. The diagnosis of these conditions requires clinical suspicion, sound interpretation of signs and symptoms, and the use of the correct imaging techniques. Here, we present the case of an 81-year-old man with a previous history of recurrent otitis media, who presented with GS and septic lateral sinus thrombosis. The clinical presentation, physiopathology, and management of these conditions are discussed.
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Affiliation(s)
- Tiago Branco
- Serviço de Medicina 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, PRT
| | | | - Vera C Santos
- Serviço de Medicina Intensiva, Hospital Prof. Doutor Fernando Fonseca, Amadora, PRT
| | - João M Lopes
- Serviço de Medicina 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, PRT
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Muacevic A, Adler JR, Sivaswamy L. An Atypical Radiologic Presentation of Right Sixth Lateral Rectus Palsy: A Case Report. Cureus 2022; 14:e32597. [PMID: 36660533 PMCID: PMC9845534 DOI: 10.7759/cureus.32597] [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: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Isolated ocular palsies are often associated with a benign process in the pediatric population but early diagnosis is critical to exclude any serious pathology. In this case, a six-year-old female with no significant past medical history presented with isolated right-eye medial deviation. The patient reported right-eye medial deviation for the past several weeks and associated double vision, but denied any pain with eye movements, other cranial nerve changes, or headaches. This case highlights the key radiologic finding which may ultimately allow for a leading diagnosis and inform further management in cases of isolated ocular nerve palsy.
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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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Jin L, Liu S, Tan S, Wang Y, Zhao Y, Yu S. Petrositis caused by fluconazole-resistant candida: case report and literature review. BMC Infect Dis 2022; 22:649. [PMID: 35896968 PMCID: PMC9327414 DOI: 10.1186/s12879-022-07637-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/20/2022] [Indexed: 11/19/2022] Open
Abstract
Background Petrositis is a rare and fatal complication associated with otitis media. It is most likely caused by bacterial infections, but in some cases it is caused by fungal infections. Case study The case in this report is associated with fungal petrositis. The clinical symptoms are: ear pain from chronic otitis media, severe headache, peripheral facial palsy and diplopia. The case was finally confirmed through imaging of middle ear, bacterial culture, pathology, and blood Metagenomic next-generation sequencing (mNGS) test. The patient was treated with sensitive antifungal drugs. Conclusion Drug treatment is conservative but efficient method in this case. mNGS can provide pathogenic reference, when antibiotic is not efficient enough for fungal infections or drug-resistant fungal infections cases. This allows we to adjust drug use for the treatment.
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Affiliation(s)
- Ling Jin
- Department of Otolaryngology, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Putuo, Shanghai, 200065, China
| | - Shuangxi Liu
- Department of Otolaryngology, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Putuo, Shanghai, 200065, China
| | - Shiwang Tan
- Department of Otolaryngology, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Putuo, Shanghai, 200065, China
| | - Yang Wang
- Department of Otolaryngology, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Putuo, Shanghai, 200065, China
| | - Yumin Zhao
- Department of Otolaryngology, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Putuo, Shanghai, 200065, China
| | - Shaoqing Yu
- Department of Otolaryngology, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Putuo, Shanghai, 200065, China.
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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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Chandran A, Sagar P, Monga R, Singh S. Unusual manifestation of Koch's disease: Gradenigo-Lannois syndrome. BMJ Case Rep 2020; 13:13/11/e236779. [PMID: 33139363 DOI: 10.1136/bcr-2020-236779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Gradenigo-Lannois syndrome or petrous apicitis is an uncommon but a morbid complication of otitis media. Traditionally treated by surgery, recent advances in imaging and antibiotics have favoured a more conservative approach. Although pyogenic organisms are the leading aetiological agent, petrous apicitis due to Koch's bacilli is not rare. We report two cases of tubercular petrositis presenting as Gradenigo's syndrome with triad of ear discharge, deep-seated retro-orbital pain and diplopia. The first patient represented a mixed infection with pyogenic organism and tuberculosis, which was successfully treated with antibiotics and antitubercular therapy. The second patient showed an acute presentation of Gradenigo's syndrome with chronic otitis media having contact with an active tuberculosis case and showed dramatic response with antitubercular treatment. Tubercular petrous apicitis must be suspected and diagnosed promptly as only specific treatment will lead to symptomatic resolution and avoid complications.
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Affiliation(s)
- Aswin Chandran
- Otorhinolaryngology & Head Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Prem Sagar
- Otorhinolaryngology & Head Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rabia Monga
- Otorhinolaryngology & Head Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shuchita Singh
- Otorhinolaryngology & Head Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Bowman C, Nakhla N, Amedu V, Patel P, O'Connor C, Houston A, Breathnach A. A rare complication of otitis media: Gradenigo's syndrome successfully managed on outpatient antimicrobial therapy. CLINICAL INFECTION IN PRACTICE 2020. [DOI: 10.1016/j.clinpr.2019.100012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Savasta S, Canzi P, Aprile F, Michev A, Foiadelli T, Manfrin M, Benazzo M. Gradenigo's syndrome with abscess of the petrous apex in pediatric patients: what is the best treatment? Childs Nerv Syst 2019; 35:2265-2272. [PMID: 31432224 DOI: 10.1007/s00381-019-04352-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Gradenigo's syndrome is defined by the classic clinical triad of ear discharge, trigeminal pain, and abducens nerve palsy. It has become a very rare nosological entity after the introduction of antibiotics, so that has been defined as the "forgotten syndrome." However, the underlying pathological process (apical petrositis) still represents a life-threatening condition that shall be immediately recognized in order to address the patient to the proper therapy. The therapy itself may be an argument of discussion: on a historical background ruled by surgery, reports of successful conservative antibiotic treatment have risen in recent years. METHODS AND RESULTS We reported a case of Gradenigo's syndrome in a child with an abscess of the left petrous apex and initial involvement of the carotid artery. After multidisciplinary evaluation, we decided to encourage conservative treatment, until complete regression was observed. DISCUSSION The available literature of the last 10 years was reviewed, with particular attention to the presence of an apical abscess and the therapeutic approach. The principles of management with regard to conservative therapy versus surgical indications are therefore examined and discussed.
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Affiliation(s)
- Salvatore Savasta
- Pediatric Clinic, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy.
| | - Pietro Canzi
- Department of Otorhinolaryngology, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Federico Aprile
- Department of Otorhinolaryngology, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Alexandre Michev
- Pediatric Clinic, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Marco Manfrin
- Department of Otorhinolaryngology, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
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Mancini AJ, Glassman RD, Chang YM, Burstein R, Ashina S. Headache in Petrous Apicitis: A Case Report of Chronic Migraine-like Headache Due to Peripheral Pathology. Headache 2019; 59:1821-1826. [PMID: 31535370 DOI: 10.1111/head.13643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To report a case of petrous apicitis that manifested as chronic migraine without aura and to discuss the pathophysiological mechanisms behind this presentation. BACKGROUND Petrous apicitis is a rare complication of acute otitis media with varied clinical presentations that stem from the close proximity of the petrous apex to numerous neurovascular structures. Headache is among the common symptoms of petrous apicitis. METHODS A case of new onset headache in the setting of petrous apicitis with symptomatic response to antibiotic therapy was reported. We provided a brief review of peripheral pathophysiological mechanisms of migraine and correlated to mechanism of headache in petrous apicitis. RESULTS A 65-year-old man with chronic otitis externa/media presented with ongoing headache fulfilling International Classification of Headache Disorders 3rd edition (ICHD-3) criteria for chronic migraine without aura that persisted despite undergoing right mastoidectomy and tympanoplasty with multiple courses of oral antibiotic therapy for his chronic otitis. MRI brain revealed petrous apicitis, otomastoiditis, and clival osteomyelitis. His imaging findings improved and his migraine-like headache completely resolved after treatment with a prolonged course of antibiotics. CONCLUSIONS Petrous apicitis can present as a headache with features of migraine, and in this case in particular, as chronic migraine without aura. The pathophysiological mechanisms that may underlie the generation of migraine-like headache in petrous apicitis may include the activation of nociceptive fibers within the periosteum of the petrous apex and clivus whose cell bodies originate in the trigeminal ganglion and upper cervical dorsal root ganglia. By treating the peripheral pathology, resolution of the headache may be achieved.
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Affiliation(s)
- Alyssa J Mancini
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rebecca D Glassman
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yu-Ming Chang
- Department of Radiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.,BIDMC Comprehensive Headache Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sait Ashina
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.,BIDMC Comprehensive Headache Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
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15
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Abstract
Gradenigo syndrome was defined as a clinical triad of otitis media, severe orbito-facial pain, and ipsilateral sixth cranial nerve palsy. It may occur as a complication of either acute or chronic otitis media. Herein, we will report a case of Gradenigo syndrome induced by suppurative chronic otitis media that was promptly diagnosed and aggressively treated.
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Gradenigo's Syndrome and Labyrinthitis: Conservative versus Surgical Treatment. Case Rep Otolaryngol 2018; 2018:6015385. [PMID: 30155332 PMCID: PMC6091283 DOI: 10.1155/2018/6015385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background Extracranial intratemporal complications of chronic suppurative otitis media (CSOM) are extremely rare. Gradenigo's syndrome is defined as a clinical triad of otitis media, severe pain originating from the trigeminal nerve, and ipsilateral sixth cranial nerve palsy. Case Report A 61-year-old man presented with chronic left ear discharge, left-sided headache, diplopia associated with vertigo, tinnitus, and hearing impairment. MRI with contrast showed asymmetrical signal changes in the bilateral petrous bone with reduced enhancement on the left with high suspicion of petrositis; in the context of chronic tympanomastoiditis, there was a 10 × 4 mm enhancing lesion in the left internal auditory meatus involving the 7th-8th nerve complex. The patient was treated conservatively with local and systemic antimicrobial agents, he had satisfactory response and improvement regarding symptoms of ear discharge, vertigo, and diplopia, but there is no remarkable response regarding hearing loss and tinnitus. Conclusion Although there is little evidence to support the use of conservative treatment in the treatment of Gradenigo's syndrome resulting from chronic ear disease, we here demonstrate successful conservative treatment of Gradenigo's syndrome.
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Affiliation(s)
- John Solms
- 1 The University of Texas Health Science Center McGovern Medical School, Houston, TX, USA
| | - Monaliza Evangelista
- 1 The University of Texas Health Science Center McGovern Medical School, Houston, TX, USA
| | - Anand Gourishankar
- 1 The University of Texas Health Science Center McGovern Medical School, Houston, TX, USA
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18
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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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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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