Petrositis Following Chronic Otitis Media without Gradenigo’s, Treated without Surgery

Petrositis is a rare complication of chronic otitis media. It is known to cause variety of intratemporal and intracranial complications, if not managed timely. Traditionally, surgery was advocated, but with better antibiotics availability, focus is now more on conservative treatment. We hereby present a rare case of petrositis, without full triad of Gradenigo’s syndrome and being managed by intravenous antibiotic only. This highlights importance of early diagnosis and treatment. A 19-year-old male presented with discharge from left ear and left sided headache, (becoming holocranial) for 2 years, with increased severity since a month. Discharge was scanty and yellowish; blood tinged occasionally and was often foul smelling. The headache was insidious, gradually worsening, aggravated by cold food intake and exposure to cold weather. He also gave history of mild hearing loss from left ear. There was history of some improvement with oral antibiotics, prescribed by local practitioners, but the relief was incomplete and lasted shortly. He had no complain of trauma to head or ear, double vision, vomiting, fever or facial weakness. Physical examination was normal especially with respect to extra ocular muscles (Fig.1) and muscles of facial expression.

Facial Neuritis as a Manifestation of Gradenigo's Syndrome

Gradenigo's syndrome (GS) is a rare, acquired syndrome caused by middle ear infections or mastoiditis. It is identified by the triad of otorrhea due to otitis media (OM), retro-orbital pain in the region innervated by the first and second divisions of the trigeminal nerve, and diplopia as a result of cranial nerve (CN) VI palsy. As a result of extension of the inflammation, the facial nerve (VII) may also be affected. GS has a poor prognosis unless promptly diagnosed and treated. Herein, we report the clinical and radiological findings observed in two children diagnosed with chronic suppurative OM, mastoiditis, and facial neuritis. Both were medically managed as cases of GS with high-dose intravenous antibiotic and full recovery was achieved a few weeks after discharge. There was no need for any surgical intervention. This report illustrates the importance of early recognition, diagnosis, and treatment of this treatable syndrome using antibiotics to prevent subsequent fatal complications and further need for surgical intervention.

Gradenigo’s and Vernet’s syndrome in an adult man with Candida mastoiditis

The authors report a case of fungal otitis media complicated by extension of the infection into adjacent structures causing apical petrositis and subsequently involvement of the jugular foramen in a 71-year-old diabetic man. First described in 1907, Gradenigo’s syndrome is a serious but rare clinical triad of acute otitis media, unilateral pain in the distribution of cranial nerve V (trigeminal) and ipsilateral cranial nerve VI (abducens) palsy that commonly presents without all three features and is therefore often missed. In this report, our patient was initially misdiagnosed as having a diabetic cranial neuropathy, and later he developed Vernet’s syndrome. Despite aggressive surgical and medical management, he did poorly and died a few weeks later. Clinicians need to be aware of this serious and life-threatening complication of otitis media in high-risk individuals with diabetes or immunocompromised states, to allow early diagnosis and improved clinical outcomes.

Unusual manifestation of Koch’s disease: Gradenigo-Lannois syndrome

Gradenigo-Lannois syndrome or petrous apicitis is an uncommon but a morbid complication of otitis media. Traditionally treated by surgery, recent advances in imaging and antibiotics have favoured a more conservative approach. Although pyogenic organisms are the leading aetiological agent, petrous apicitis due to Koch’s bacilli is not rare. We report two cases of tubercular petrositis presenting as Gradenigo’s syndrome with triad of ear discharge, deep-seated retro-orbital pain and diplopia. The first patient represented a mixed infection with pyogenic organism and tuberculosis, which was successfully treated with antibiotics and antitubercular therapy. The second patient showed an acute presentation of Gradenigo’s syndrome with chronic otitis media having contact with an active tuberculosis case and showed dramatic response with antitubercular treatment. Tubercular petrous apicitis must be suspected and diagnosed promptly as only specific treatment will lead to symptomatic resolution and avoid complications.

Gradenigo’s Syndrome and Bacterial Meningitis in a Patient with a Petrous Apex Cholesterol Granuloma

Gradenigo’s syndrome (GS) classically involves a triad of ear pain due to acute or chronic otitis media (OM), facial or retro-orbital pain in the distribution of the trigeminal nerve, and an abducens nerve palsy. The simultaneous presentation of all three components has become less common in cases of GS reported in the literature, particularly in the era of antibiotics effective against typical organisms attributed to OM and petrous apicitis. In addition to infectious petrous apicitis arising directly from OM, more recent cases of GS are attributed to the compression of the same traversing cranial nerves in the presence of various expansile petrous apex (PA) lesions, both benign and malignant. We report a case of a 24-year-old male who presented initially with nausea, fever, photophobia, left-sided retro-orbital pain, and headache. He was diagnosed with bacterial meningitis by lumbar puncture and treated with empiric antibiotics, with CSF eventually revealing nontypeable Haemophilus influenzae. Several days into his course, he developed diplopia with leftward gaze. Brain imaging revealed an expansile, erosive PA cholesterol granuloma with associated contiguous dural and leptomeningeal enhancement. The patient improved with antibiotics and eventually underwent surgical intervention. This atypical presentation of GS with a rare complication of meningitis in the setting of a PA granuloma demonstrates the importance of early recognition of this syndrome, as well as consideration of added surgical intervention in patients with pre-existing petrous lesions at potentially higher risk of dangerous complications of GS.