Conservative management of petrous apex abscess and Gradenigo's syndrome in a diabetic patient: Case report and literature review

Guimarães, Guilherme Corrêa; Freitas, Paola Piva de; Silva, Vagner Antônio Rodrigues da; Castilho, Arthur Menino

doi:10.1002/ccr3.3625

Cited by 3 publications

(5 citation statements)

References 18 publications

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“…The need for medical therapy is undeniable; however, for further treatments it is necessary to evaluate case by case based on the patient and disease factors [36]. Etiology secondary to infectious processes requires longterm broad-spectrum antibiotics [3], in particular in cases of abscesses located in regions that are difficult to reach surgically due to surgical limitations or possible sequelae related to surgery [37]. Best clinical outcomes seem to be in those patients subjected to only medical therapy [8].…”

Section: Discussionmentioning

confidence: 99%

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Refractory Pseudomonas Osteomyelitis of the Skull Base With Gradenigo’s Syndrome: Early Dysphagia and Late Abducens Nerve Palsy

Mammarella,

Loperfido,

Velletrani

et al. 2024

J Med Cases

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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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Section: Discussionmentioning

confidence: 99%

“…An elderly patient's peculiarity [5,14,[39][40][41] is the presence of neurological defect, usually diplopia that correlates with Dorello's canal involvement developing in the early stages. Coexistence of predisposing conditions includes diseases like diabetes mellitus [29,37] and immunodeficiency [11].…”

Section: Discussionmentioning

confidence: 99%

Refractory Pseudomonas Osteomyelitis of the Skull Base With Gradenigo’s Syndrome: Early Dysphagia and Late Abducens Nerve Palsy

Mammarella,

Loperfido,

Velletrani

et al. 2024

J Med Cases

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“…Gradenigo's syndrome often arises secondary to petrous apicitis, which is the infection of the petrous apex due to the contiguous spread of infection from mastoid air cell tracts into a pneumatized petrous apex [2,3]. Petrous apicitis may arise as a complication of acute otitis media or mastoiditis and is thus most frequently associated with bacterial etiologies [2].…”

Section: Introductionmentioning

confidence: 99%

“…Petrous apicitis may arise as a complication of acute otitis media or mastoiditis and is thus most frequently associated with bacterial etiologies [2]. Other causes of Gradenigo's syndrome include neoplastic lesions, aspergillus, or nontuberculous mycobacterial infections, though these are far less common [3].…”

Section: Introductionmentioning

confidence: 99%

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Neurosurgical Intervention in the Treatment of Gradenigo Syndrome: A Case Report

Rifai,

Cassimatis,

Soliman MD

2023

Cureus

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Gradenigo syndrome comprises a clinical triad: retro-orbital pain, sixth cranial nerve palsy, and purulent otorrhea. This clinical syndrome often arises secondary to petrous apicitis, which is an infection of the petrous apex that may result from the contiguous spread of infection from the ear or mastoid. This syndrome is very rare, and based on the existing literature, the initial approach for treatment involves long-term administration of IV antibiotics, which may resolve the underlying infection related to petrous apicitis, mastoiditis, and/or otitis media.In this case, the patient, a 69-year-old male, had a progression of several symptoms, including recurrent headaches, diplopia, hearing loss, and dysphagia, despite long-term antibiotic therapy and a prior mastoidectomy. Thus, the neurosurgical team decided to intervene via anterior petrous bone resection via the Kawase approach, which unfortunately did not result in the resolution of the patient's symptoms. The patient continued to have symptoms of Gradenigo syndrome, including sixth cranial nerve palsy and was subsequently referred to outpatient follow-up for further management. In this report, we present the patient's case and a brief review of the literature concerning various treatment modalities for Gradenigo syndrome.

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Steroid-Responsive Gradenigo’s Syndrome Mimicking Subdural Hematoma

Liu¹,

Yeh²,

Lin³

et al. 2021

Cureus

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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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Conservative management of petrous apex abscess and Gradenigo's syndrome in a diabetic patient: Case report and literature review

Abstract: The case reported evidences the possibility of nonsurgical treatment in patients with abscesses located in regions difficult to reach surgically due to surgical limitations or possible sequelae related to surgical procedure.

Cited by 3 publications

References 18 publications

Refractory Pseudomonas Osteomyelitis of the Skull Base With Gradenigo’s Syndrome: Early Dysphagia and Late Abducens Nerve Palsy

Refractory Pseudomonas Osteomyelitis of the Skull Base With Gradenigo’s Syndrome: Early Dysphagia and Late Abducens Nerve Palsy

Neurosurgical Intervention in the Treatment of Gradenigo Syndrome: A Case Report

Steroid-Responsive Gradenigo’s Syndrome Mimicking Subdural Hematoma

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