Giuseppe Gradenigo: Much more than a syndrome! Historical vignette

Bilateral papilledema and abducens nerve palsy following cerebral venous sinus thrombosis due to Gradenigo's syndrome in a pediatric patient

Purpose

To report a case of bilateral papilledema and abducens nerve palsy following cerebral venous sinus thrombosis in a 9-year-old female with undiagnosed Gradenigo's Syndrome.

Observations

The patient presented to our Emergency Room with a unilateral left 6th nerve palsy, left eye relative afferent pupillary defect, and bilateral papilledema. She underwent cranial magnetic resonance imaging with gadolinium contrast and magnetic resonance venography, which diagnosed a left mastoiditis, left sigmoid sinus and jugular vein thrombosis. The patient underwent urgent mastoidectomy and myringotomy with tube placement and was admitted for adequate treatment with intravenous antibiotics and anticoagulants.

Conclusions and importance

Gradenigo's syndrome is a rare complication of otitis media, and even rarer is cerebral venous thrombosis. This potentially life-threatening situation requires immediate surgical and antibiotic therapy. Ocular symptoms can be the initial signs of this illness.

Gradenigo's Syndrome in a Patient with Chronic Suppurative Otitis Media, Petrous Apicitis, and Meningitis

Patient: Male, 58

Final Diagnosis: Bacterial meningitis

Symptoms: Altered mental status • headache • neck stiffness • vomiting

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

Gruber, Gradenigo, Dorello, and Vail: key personalities in the historical evolution and modern-day understanding of Dorello's canal

A century ago an ambitious young anatomist in Rome, Primo Dorello, who sought to understand the cause of abducent nerve palsy that often occurred in patients with severe middle ear infections, conducted intricate studies on the intracranial course of the nerve. In his findings, he identified that the abducent nerve passes through a narrow sinus near the apex of the petrous bone, which formed an osteofibrous canal. Dorello suggested that in this enclosed region the abducent nerve may be particularly vulnerable to compression due to the vascular edema accompanying the infection. Although his work was widely appreciated, it was not well received by all. Interestingly, Giuseppe Gradenigo, one of the most prominent Italian otologists of the early 20th century, who was known for his work on a triad of symptoms (Gradenigo's syndrome) that accompanies petrous apicitis, a result of severe middle ear infections, was obstinate in his criticism of Dorello's findings. Thus a scientific duel began, with a series of correspondence between these two academics-one who was relatively new to the otological community (Dorello) and one who was well reputed in that community (Gradenigo). The disagreement ultimately ebbed in 1909, when Dorello published a report in response to Gradenigo's criticisms and convinced Gradenigo to change his views. Today Dorello's canal is widely recognized as a key landmark in skull base surgery of the petroclival region and holds clinical significance due to its relation to the abducent nerve and surrounding vascular structures. Yet, although academics such as Dorello and Gradenigo are recognized for their work on the canal, it is important not to forget the others throughout history who have contributed to the modern-day understanding of this anatomical structure. In fact, although the level of anatomical detail found in Dorello's work was previously unmatched, the first description of the canal was made by the experienced Austrian anatomist Wenzel Leopold Gruber in 1859, almost 50 years prior to Dorello's landmark publication. Another critical figure in building the understanding of Dorello's canal was Harris Holmes Vail, a young otolaryngologist from Harvard Medical School, who in 1922 became the first person to describe Dorello's canal in the English language. Vail conducted his own detailed anatomical studies on cadavers, and his publication not only reaffirmed Dorello's findings but also immortalized the eponym used today-"Dorello's canal." In this article the authors review the life and contributions of Gruber, Dorello, Gradenigo, and Vail, four men who played a critical role in the discovery of Dorello's canal and paved the way toward the current understanding of the canal as a key clinical and surgical entity.

Gradenigo syndrome: unusual consequence of otitis media

INTRODUCTION

In 1904, Giuseppe Gradenigo published his case series on the triad of ipsilateral abducens nerve palsy, facial pain in the trigeminal nerve distribution, and suppurative otitis media, which would subsequently be referred to as Gradenigo syndrome.

CASE REPORT

Our patient was a 36-year-old female, 23 weeks pregnant, with a 6-day history of right-sided otalgia and hearing loss and a 4-day history of purulent otorrhea, who presented with severe, holocephalic headache, meningeal signs, fever, photophobia, and mental status decline. Lumbar puncture yielded a white blood cell count of 1,559 cells/mm(3) with 95% polymorphonuclear leukocytes, a red blood cell count of 111 cells/mm(3), a protein level of 61 mg/dl, and a glucose level of <40 mg/dl. Cerebrospinal fluid Gram stain showed Gram-positive diplococci, which were subsequently identified as Streptococcus pneumoniae and treated with ceftriaxone. On the second hospital day, she developed horizontal diplopia due to right abducens nerve palsy and right mydriasis. Both symptoms resolved on the third hospital day. Erosion of temporal bone and opacification of mastoid air cells was shown on CT scan. A CT venogram showed an irregularity of the left transverse and superior sagittal sinuses. She was treated with enoxaparin for possible sinus thrombosis.

DISCUSSION

This case demonstrates rare but serious sequelae of otitis media and Gradenigo syndrome. Holocephalic headache from meningitis masked trigeminal pain. Involvement of the ipsilateral petrous apex and surrounding structures on imaging and clinical improvement with antibiotic treatment supports Gradenigo syndrome over intracranial hypertension due to venous sinus thrombosis as the cause of the abducens nerve palsy.