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

Journal of Medical Case Reports, Jun 2014

Introduction Gradenigo’s syndrome is nowadays a rare condition characterized by a triad of otorrhea, facial pain with trigeminal nerve involvement and abducens nerve palsy. Most cases are caused by medial extension of acute otitis media into a pneumatized petrous apex and surgical drainage is usually the treatment of choice. We present a case highlighting the pathological mechanism of this disease, demonstrate rare radiological findings associated with this patient, and showcase successful medical treatment without surgical intervention. Case presentation A 63-year-old Thai man presented with complete Gradenigo triad as a complication of chronic otomastoiditis in spite of clinical history of previous radical mastoidectomy and a nonpneumatization of the petrous apex. Magnetic resonance imaging showed abnormal prominent enhancement at the roof of his right temporal bone, and the dura overlying the floor of right middle cranial fossa and right cavernous sinus. Magnetic resonance imaging also detected right petrous apicitis. With the use of intravenous antibiotics and topical antibiotic eardrops, recovery was observed within 5 days with complete resolution within 2 months. Conclusions Although there is little evidence to support the use of medical therapy in the treatment of Gradenigo’s syndrome resulting from chronic ear disease, we here demonstrate successful conservative treatment of Gradenigo’s syndrome following chronic otitis media in a patient who underwent previous radical mastoidectomy.

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

Journal of Medical Case Reports Gradenigo's syndrome secondary to chronic otitis media on a background of previous radical mastoidectomy: a case report Yuvatiya Plodpai 2 Siriporn Hirunpat 1 Weerawat Kiddee 0 0 Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University , Hatyai, Songkhla 90110 , Thailand 1 Department of Radiology, Faculty of Medicine, Prince of Songkla University , Hatyai, Songkhla 90110 , Thailand 2 Department of Otolaryngology, Faculty of Medicine, Prince of Songkla University , Hatyai, Songkhla 90110 , Thailand Introduction: Gradenigo's syndrome is nowadays a rare condition characterized by a triad of otorrhea, facial pain with trigeminal nerve involvement and abducens nerve palsy. Most cases are caused by medial extension of acute otitis media into a pneumatized petrous apex and surgical drainage is usually the treatment of choice. We present a case highlighting the pathological mechanism of this disease, demonstrate rare radiological findings associated with this patient, and showcase successful medical treatment without surgical intervention. Case presentation: A 63-year-old Thai man presented with complete Gradenigo triad as a complication of chronic otomastoiditis in spite of clinical history of previous radical mastoidectomy and a nonpneumatization of the petrous apex. Magnetic resonance imaging showed abnormal prominent enhancement at the roof of his right temporal bone, and the dura overlying the floor of right middle cranial fossa and right cavernous sinus. Magnetic resonance imaging also detected right petrous apicitis. With the use of intravenous antibiotics and topical antibiotic eardrops, recovery was observed within 5 days with complete resolution within 2 months. Conclusions: Although there is little evidence to support the use of medical therapy in the treatment of Gradenigo's syndrome resulting from chronic ear disease, we here demonstrate successful conservative treatment of Gradenigo's syndrome following chronic otitis media in a patient who underwent previous radical mastoidectomy. Gradenigo's syndrome; Mastoidectomy; Petrous apicitis - Introduction Gradenigos syndrome (GS) was first described in 1904 by Guiseppe Gradenigo [1]. It is defined as a clinical triad of otitis media, severe pain originating from the trigeminal nerve, and ipsilateral sixth cranial nerve palsy. The syndrome is an exceedingly rare complication of chronic otitis media in the era of the widespread use of antibiotics and easily accessible health-care services. Classically, the symptoms are related to inflammation of the petrous apex of the temporal bone, a condition termed petrous apicitis, which is usually caused by medial extension of acute otitis media into a pneumatized petrous apex, located near the trigeminal ganglion and sixth cranial nerve. To the best of our knowledge, GS developing in a patient with a previous radical mastoidectomy and nonpneumatization of the petrous apex has never been reported. We highlight a different pathological disease mechanism and demonstrate rare radiologic findings. A dramatic response was achieved by administering intravenous antibiotics following nonsurgical management. Case presentation A 63-year-old Thai man with a history of right-sided otorrhea presented with a 2-day history of right abducens nerve palsy and severe headache. His headache began 1 month ago concomitant with right-sided otorrhea. At that time, his otorrhea improved temporarily after taking empirical systemic and otic antibiotics, but the headache did not. Five days prior to presentation, he experienced worsening headache, nausea, and vomiting. Emergency computed tomography (CT) was initially reported as an unremarkable study. Three days later, he developed Figure 1 Otoscopic view showing an inflamed right mastoid cavity (black arrow) with a high facial ridge (white arrow) post-radical mastoidectomy. binocular diplopia in a primary gaze position that worsened when looking to a right gaze. The constant headache had begun with ipsilateral pain in his right frontal and retro-orbital area radiating to his whole head. His medical history was unremarkable with the exception of a right ear radical mastoidectomy performed 30 years previously. He was lost to follow-up and still had persistent right ear discharge. An otoscopy of his right ear revealed mucoid discharge and granulation tissue occupying the middle ear and mastoid cavity, which was inflamed with a high facial ridge (Figure 1, see white arrow). His left ear contained an intact tympanic membrane and a narrowing of the external ear canal. Ophthalmologic examination revealed an isolated right-sided abducens nerve palsy. All other neurological examination findings were unremarkable. He also had a high erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count with a predominance of neutrophils. Moderate right-sided mixedtype hearing loss was evidenced on audiometry. Ear swab cultures were (...truncated)


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Yuvatiya Plodpai, Siriporn Hirunpat, Weerawat Kiddee. Gradenigo’s syndrome secondary to chronic otitis media on a background of previous radical mastoidectomy: a case report, Journal of Medical Case Reports, 2014, pp. 217, 8, DOI: 10.1186/1752-1947-8-217