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[Isolated apical petrositis: an atypical case of Gradenigo's syndrome]
P Zengel1, M Wiekström, L Jäger
1Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Klinikum Grosshadern, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377, München.
Abstract:
In 1904 Guiseppe Gradenigo described an infection of the apex of the petrous part of the temporal bone from acute otitis media with the clinical symptoms of unilateral pain around the eye, diplopia due to sixth nerve paralysis and persistant otorrhea. While this infection became evident by inward extension from petrositis in the majority of fatal cases from acute otitis media in the preantibiotic era, it has now become very rare. Today, cases mainly derive from cholesteatomas or chronic osteomyelitis of the petrous bone. However, due to intense antibiotic treatment in acute otitis media clinical signs of petrositis may be less typical compared to former times. We report on a 12-year-old boy with rapid onset of sixth nerve paralysis without clinical signs of acute otitis media or mastoiditis. CT and NMR imaging confirmed infection of the petrous apex. He was treated by mastoidectomy with exploration of a posterior cell group from the epitympanon around the semicircular canals and subsequent high dose intravenous antibiotics. The patient recovered without any loss of inner ear or facial nerve function. The paralysis of the sixth nerve disappeared completely within 6 weeks.
Insights
Gradenigo syndrome, a rare petrous apex infection, can cause sixth nerve paralysis. Early diagnosis and treatment with mastoidectomy and antibiotics are crucial for recovery.
Area of Science:
- Otolaryngology
- Neurology
- Infectious Diseases
Background:
- Gradenigo syndrome, characterized by otitis media, retro-orbital pain, and abducens nerve palsy, was historically linked to petrous apex infections.
- While rare in the antibiotic era, petrous apex osteomyelitis can arise from cholesteatoma or chronic infections.
Observation:
- A 12-year-old boy presented with acute sixth nerve paralysis without typical acute otitis media or mastoiditis symptoms.
- Imaging revealed petrous apex infection, suggesting a modern presentation of Gradenigo syndrome.
Findings:
- Surgical mastoidectomy with exploration and high-dose intravenous antibiotics successfully treated the petrous apex infection.
- The patient experienced complete resolution of sixth nerve palsy within six weeks, preserving auditory and facial nerve function.
Implications:
- This case highlights the importance of considering Gradenigo syndrome even with atypical presentations in the current antibiotic landscape.
- Prompt diagnosis and multimodal treatment, including surgical intervention and antibiotics, are vital for favorable outcomes in rare petrous apex infections.
