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

Abstract

Patient: Male, 58Final Diagnosis: Bacterial meningitisSymptoms: Altered mental status • headache • neck stiffness • vomitingMedication: —Clinical Procedure: —Specialty: Infectious DiseasesObjective:Rare diseaseBackground:Gradenigo’s syndrome includes the triad of suppurative otitis media, ipsilateral sixth (abducens) cranial nerve palsy and facial pain in the distribution of the fifth (trigeminal) cranial nerve. Gradenigo’s syndrome is rare, and the diagnosis is easily overlooked. This case is the first to report Gradenigo’s syndrome presenting with meningitis on a background of chronic suppurative otitis media (CSOM) and petrous apicitis (apical petrositis).Case Report:A 58-year-old male African American presented with headaches and confusion. Magnetic resonance imaging (MRI) of the head showed petrous apicitis with mastoiditis and abscess formation in the cerebellomedullary cistern (cisterna magna). The case was complicated by the development of palsy of the fourth (trochlear) cranial nerve, fifth (trigeminal) cranial nerve, and sixth (abducens) cranial nerve, with radiological changes indicating infection involving the seventh (facial) cranial nerve, and eighth (vestibulocochlear) cranial nerve. Cerebrospinal fluid (CSF) culture results were positive for Klebsiella pneumoniae, sensitive to ceftriaxone. The patient improved with surgery that included a left mastoidectomy and debridement of the petrous apex, followed by a ten-week course of antibiotics. Follow-up MRI showed resolution of the infection.Conclusions:This report is of an atypical case of Gradenigo’s syndrome. It is important to recognize that the classical triad of Gradenigo’s syndrome, suppurative otitis media, ipsilateral sixth (abducens) cranial nerve palsy and facial pain in the distribution of the fifth (trigeminal) cranial nerve, may also involve chronic suppurative otitis media (CSOM), which may lead to involvement of other cranial nerves, petrous apicitis (apical petrositis), and bacterial meningitis.

Gradenigo’s Syndrome with Carotid Septic Stenosis

“…We report an atypical and potentially life-threatening case of GS. As previously reported, the typical triad of GS is not always seen, and symptoms should be taken in the context of all the patients' presenting symptoms, signs, and investigations [12].…”

“…Our case report stands out for its relatively short intravenous antibiotic therapy duration. Previous reports have described variable intravenous antibiotic therapy between 10 and 64 days [12,15]. Undoubtedly, petrositis caused by infection is equivalent to osteomyelitis, which needs intensive and prolonged antibiotic treatment to avoid relapse [15].…”

Gradenigo's syndrome presenting as IX and X cranial nerve palsy without clinically apparent ear infection: A case report and review of literature

“…Gradenigo's syndrome (GS) is one of the rare complications of OM's intratemporal spread that was first recognized by Gradenigo as a condition presenting with unilateral facial pain (V nerve involvement), lateral gaze paralysis (VI nerve involvement), and otorrhea [ 6 ]. Various atypical manifestations like otic meningitis, VII nerve involvement, and lack of otorrhea have also been reported in the literature, so the classic triad has largely fallen out of favor [ 3 , 7 , 8 ]. Given the anatomical contiguity of neural structures, and our limited understanding based largely on case reports and case series, a spectrum of atypical clinical presentations are likely to be reported in the future as well.…”

Akute Kopfschmerzen in der Notaufnahme

“…Zudem können die Symptome Kopfschmerzen und Tinnitus bestehen. Diese Entität ist seit der breitflächigen Anwendung von Antibiotika selten geworden und wird leicht übersehen, wenn das klinische Bild unvollständig und atypisch ist [66,67].…”