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
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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)