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Liu Y, Yeh PK, Lin YP, Sung YF. Steroid-Responsive Gradenigo's Syndrome Mimicking Subdural Hematoma. Cureus 2021; 13:e19547. [PMID: 34917431 PMCID: PMC8668413 DOI: 10.7759/cureus.19547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 01/18/2023] Open
Abstract
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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Affiliation(s)
- Yi Liu
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
| | - Po-Kuan Yeh
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
| | - Yu-Pang Lin
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
| | - Yueh-Feng Sung
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, TWN
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Gradenigo's syndrome in a woman with systemic lupus erythematosus. Acta Neurol Belg 2020; 120:179-180. [PMID: 31586301 DOI: 10.1007/s13760-019-01216-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
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Reddy RK, Reddy RK, Jyung RW, Eloy JA, Liu JK. Gruber, Gradenigo, Dorello, and Vail: key personalities in the historical evolution and modern-day understanding of Dorello's canal. J Neurosurg 2015; 124:224-33. [PMID: 26115474 DOI: 10.3171/2014.12.jns14835] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A century ago an ambitious young anatomist in Rome, Primo Dorello, who sought to understand the cause of abducent nerve palsy that often occurred in patients with severe middle ear infections, conducted intricate studies on the intracranial course of the nerve. In his findings, he identified that the abducent nerve passes through a narrow sinus near the apex of the petrous bone, which formed an osteofibrous canal. Dorello suggested that in this enclosed region the abducent nerve may be particularly vulnerable to compression due to the vascular edema accompanying the infection. Although his work was widely appreciated, it was not well received by all. Interestingly, Giuseppe Gradenigo, one of the most prominent Italian otologists of the early 20th century, who was known for his work on a triad of symptoms (Gradenigo's syndrome) that accompanies petrous apicitis, a result of severe middle ear infections, was obstinate in his criticism of Dorello's findings. Thus a scientific duel began, with a series of correspondence between these two academics-one who was relatively new to the otological community (Dorello) and one who was well reputed in that community (Gradenigo). The disagreement ultimately ebbed in 1909, when Dorello published a report in response to Gradenigo's criticisms and convinced Gradenigo to change his views. Today Dorello's canal is widely recognized as a key landmark in skull base surgery of the petroclival region and holds clinical significance due to its relation to the abducent nerve and surrounding vascular structures. Yet, although academics such as Dorello and Gradenigo are recognized for their work on the canal, it is important not to forget the others throughout history who have contributed to the modern-day understanding of this anatomical structure. In fact, although the level of anatomical detail found in Dorello's work was previously unmatched, the first description of the canal was made by the experienced Austrian anatomist Wenzel Leopold Gruber in 1859, almost 50 years prior to Dorello's landmark publication. Another critical figure in building the understanding of Dorello's canal was Harris Holmes Vail, a young otolaryngologist from Harvard Medical School, who in 1922 became the first person to describe Dorello's canal in the English language. Vail conducted his own detailed anatomical studies on cadavers, and his publication not only reaffirmed Dorello's findings but also immortalized the eponym used today-"Dorello's canal." In this article the authors review the life and contributions of Gruber, Dorello, Gradenigo, and Vail, four men who played a critical role in the discovery of Dorello's canal and paved the way toward the current understanding of the canal as a key clinical and surgical entity.
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Affiliation(s)
| | | | - Robert W Jyung
- Otolaryngology-Head & Neck Surgery, Rutgers University, New Jersey Medical School; and
| | - Jean Anderson Eloy
- Departments of 1 Neurological Surgery and.,Otolaryngology-Head & Neck Surgery, Rutgers University, New Jersey Medical School; and.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - James K Liu
- Departments of 1 Neurological Surgery and.,Otolaryngology-Head & Neck Surgery, Rutgers University, New Jersey Medical School; and.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers University, New Jersey Medical School, Newark, New Jersey
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Abstract
The syndrome of constant otorrhea, headache, and diplopia, which is attributed to inflammation of the petrous apex, is known as Gradenigo's syndrome. It is often the result of chronic otitis media with long-standing purulent otorrhea. It has traditionally been treated surgically, but recent advances in imaging, allied with improved antibiotic treatment, have allowed for consideration of non-surgical management of these cases. A 60-year-old woman presented to the emergency department with 7 days of right-sided headache, facial pain, and diplopia. She awoke with the headache and facial pain 7 days earlier. She was without any preceding infectious symptoms including ear pain, sinus congestion, sore throat, and cough, and she denied fevers and chills. Examination demonstrated a right eye lateral gaze palsy and reproducible diplopia. Computed tomography studies demonstrated the possibility of fluid in the petrous apex of the temporal bone. A follow-up magnetic resonance imaging study confirmed a moderate amount of fluid in the right petrous apex consistent with Gradenigo's syndrome. Imaging with computed tomography and magnetic resonance is an important tool in the evaluation of petrous apex lesions. Gradenigo's syndrome is a rare condition that does not always present with the classical triad of otorrhea, headache, and diplopia. Appropriate management requires antibiotic treatment and possible surgical intervention.
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Dorn M, Liener K, Rozsasi A, Keck T. Prolonged diplopia following sinus vein thrombosis mimicking Gradenigo's syndrome. Int J Pediatr Otorhinolaryngol 2006; 70:741-3. [PMID: 16280172 DOI: 10.1016/j.ijporl.2005.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2005] [Revised: 09/12/2005] [Accepted: 09/13/2005] [Indexed: 11/25/2022]
Abstract
We report about a boy with the symptoms of Gradenigo's syndrome (abducens nerve palsy, acute otitis media, unilateral headache). The MR imaging showed a sinus vein thrombosis instead of the expected petroapicitis. After 2 weeks of conservative therapy with antibiotics and anticoagulation, without any clinical effort the boy underwent a mastoidectomy. Headache and otitis media recovered quickly but the diplopia still remained after 25 months.
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Affiliation(s)
- Matthias Dorn
- Department of Otorhinolaryngology, University of Ulm, Frauensteige 12, 89075 Ulm, Germany
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Lee YH, Lee NJ, Kim JH, Song JJ. CT, MRI and gallium SPECT in the diagnosis and treatment of petrous apicitis presenting as multiple cranial neuropathies. Br J Radiol 2005; 78:948-51. [PMID: 16177020 DOI: 10.1259/bjr/71475327] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We present a rare case of petrous apicitis initiated by middle ear inflammation in a diabetic patient with multiple cranial neuropathies for early diagnosis of this potentially life-threatening condition. The lesion appeared as opacification of middle ear, petrous apex with aggressive bony destruction on CT and diffuse petrosal T(1) hypointensity with adjacent soft tissue propagation on MRI. Gallium-67 single-photon emission computed tomography (SPECT) scan also contributed to evaluate response to therapy.
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Affiliation(s)
- Y H Lee
- Department of Radiology, Head and Neck Surgery, Korea University College of Medicine, Seoul
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Villa G, Lattere M, Rossi A, Di Pietro P. Acute onset of abducens nerve palsy in a child with prior history of otitis media: a misleading sign of Gradenigo syndrome. Brain Dev 2005; 27:155-9. [PMID: 15668058 DOI: 10.1016/j.braindev.2004.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2003] [Revised: 02/02/2004] [Accepted: 02/16/2004] [Indexed: 10/26/2022]
Abstract
Gradenigo syndrome in children during otitis media is a very rare complication since the use of antibiotics: nevertheless, it must be taken into account in case of otitis media, abducens nerve paralysis and facial pain in regions innervated by the first and second division of trigeminal nerve. We report the case of a 4-year-old boy whose neurological signs and clinical history prompted us to entertain a diagnosis of Gradenigo syndrome, which was not confirmed by CT and MRI findings, revealing otomastoiditis and sinus thrombosis.
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Affiliation(s)
- Giovanna Villa
- Emergency Department of Paediatrics G. Gaslini Children's Hospital Largo G. Gaslini, 5 16147 Genova, Italy.
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Marianowski R, Rocton S, Ait-Amer JL, Morisseau-Durand MP, Manach Y. Conservative management of Gradenigo syndrome in a child. Int J Pediatr Otorhinolaryngol 2001; 57:79-83. [PMID: 11165646 DOI: 10.1016/s0165-5876(00)00442-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Gradenigo syndrome consists of the association of otitis media, facial pain in regions innervated by the first and second division of trigeminal nerve and abducens nerve paralysis. It is caused by osteitis of the petrous apex (PA) and is a very rare complication of otitis media. Its treatment usually consists in mastoidectomy and antibiotics. We report a case of a 6-year-old child, which was managed medically with a positive outcome.
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Affiliation(s)
- R Marianowski
- Department of Pediatric Otorhinolaryngology, Hôpital Necker-Enfants Malades, 11 avenue Franco-Russe, Paris 75007, France.
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Davé AV, Diaz-Marchan PJ, Lee AG. Clinical and magnetic resonance imaging features of Gradenigo syndrome. Am J Ophthalmol 1997; 124:568-70. [PMID: 9323957 DOI: 10.1016/s0002-9394(14)70882-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To describe the clinical and magnetic resonance imaging findings of a patient with Gradenigo syndrome. METHODS A 4 1/2-year-old boy developed Gradenigo syndrome with unilateral facial pain, ophthalmoplegia, and facial weakness secondary to ipsilateral otitis media. The clinical, laboratory, and radiologic findings are discussed. RESULTS The patient was treated with antibiotics and had complete resolution of symptoms and signs. CONCLUSION Ophthalmologists should be aware of the potential for petrosal involvement of cranial nerves secondary to otitis media and Gradenigo syndrome.
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Affiliation(s)
- A V Davé
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
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Abstract
Three cases of patients with acute middle ear infections complicated by a sixth nerve palsy are described. The possible causes of sixth nerve palsy in such cases are discussed. We propose that where there is a sixth nerve palsy without petrositis and without raised intracranial pressure, it can arise as a result of spreading phlebitis along the inferior petrosal sinus from the lateral sinus.
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Affiliation(s)
- J J Homer
- Department of Otorhinolaryngology-Head and Neck Surgery, Queens Medical Centre, Nottingham, UK
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Abstract
We report the case of an 8-year-old girl with Gradenigo's syndrome. Involvement of the petrous portion of the left temporal bone was demonstrated by CT and an inflammatory lesion of the left petrous apex was clearly shown by MRI, which is useful in diagnosis and management of apical petrositis.
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Affiliation(s)
- T Murakami
- Department of Pediatric Cardiology, Heart Institute of Japan, Tokyo Women's Medical College, 8-1 Kawada-cho, Sinjuku-ku, Tokyo 162, Japan
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Hardjasudarma M, Edwards RL, Ganley JP, Aarstad RF. Magnetic resonance imaging features of Gradenigo's syndrome. Am J Otolaryngol 1995; 16:247-50. [PMID: 7573745 DOI: 10.1016/0196-0709(95)90151-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- M Hardjasudarma
- Department of Radiology, Louisiana State University Medical Center, Shreveport 71130, USA
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Abstract
The case is presented of a 13-year-old boy with recurrent episodes of otitis media who developed Gradenigo syndrome. Mastoid and petrous bone involvement were demonstrated by CT. Symptoms resolved with antibiotic treatment.
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Affiliation(s)
- S Tutuncuoglu
- Department of Paediatrics, Ege University Hospital, Bornova, Izmir, Turkey
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