Petrositis caused by fluconazole-resistant candida: case report and literature review.

BACKGROUND: Petrositis is a rare and fatal complication associated with otitis media. It is most likely caused by bacterial infections, but in some cases it is caused by fungal infections. CASE STUDY: The case in this report is associated with fungal petrositis. The clinical symptoms are: ear pain from chronic otitis media, severe headache, peripheral facial palsy and diplopia. The case was finally confirmed through imaging of middle ear, bacterial culture, pathology, and blood Metagenomic next-generation sequencing (mNGS) test. The patient was treated with sensitive antifungal drugs. CONCLUSION: Drug treatment is conservative but efficient method in this case. mNGS can provide pathogenic reference, when antibiotic is not efficient enough for fungal infections or drug-resistant fungal infections cases. This allows we to adjust drug use for the treatment.

[Rare observation of petrositis complicated by parapharyngeal abscess in an 8-year-old patient]. / Redkoe nablyudenie petrozita, oslozhnennogo parafaringeal'nym abstsessom, u patsienta 8 let.

A clinical case of diagnosis and treatment of an 8-year-old patient with bilateral acute suppurative otitis media (ASOM) complicated by left mastoiditis and petrositis is presented. By itself, such a rare complication of ASOM as petrositis manifested itself not in the form of the classic Gradenigo triad, but as a parapharyngeal abscess (PPA), due to the destruction of the lower wall of the temporal bone pyramid. Complications arose as a result of contact and hematogenous pathways for the spread of the infection, which debuted in the middle ear cavities 1 month before the patient was admitted to the hospital. The combination of factors such as an aggressive pathogen, the anatomical structure of the middle ear, a decrease in the immune reactivity of the child's body, the spread of infection through the lower cells of the temporal bone pyramid and the lack of timely antibiotic therapy, led to destructive changes in the bony walls of the temporal bone and the spread of a purulent process to the temporal pyramid bones, and then to the parapharyngeal space. The destruction by inflammation of the lower wall of the pyramid of the temporal bone led to the development of PPA, and not meningoencephalitis, which could have fatal consequences.

Gradenigo's syndrome: A common infection with uncommon consequences.

Acute otitis media is a common diagnosis encountered by emergency medicine providers. With appropriate antibiotic treatment, patients with otitis media, in general, have minimal long-term sequela from their underlying infection (Limb et al., 2017 [1]). However, untreated cases can develop life-threatening complications that require prompt intervention. We report a case of an 8-year-old that developed Gradenigo's syndrome, a condition characterized by the triad of otitis media, facial pain in the distribution of the trigeminal nerve, and abducens nerve palsy (Yeung and Lustig, 2016; Janjua et al., 2016; Kantas et al., 2010; Motamed and Kalan, n.d.; Vita Fooken Jensen et al., 2016 [2-6]). Signs and symptoms are often subtle, so a high-level of suspicion is required in order not to miss this potentially fatal process.

Atypical Gradenigo's syndrome in a pediatric case: A critical review of neuroimaging.

Gradenigo's syndrome, a rare but serious complication of otitis media, encompasses a triad of symptoms including otalgia, facial palsy, and abducens nerve palsy, pointing to the involvement of the petrous apex. This case report presents an 11-year-old boy with an atypical manifestation of Gradenigo's syndrome, characterized by the absence of classic features such as abducens nerve palsy and purulent otorrhea. MRI findings were significant for petrous apicitis extending to Meckel's cave and the cavernous sinus, along with abscess formation and clivus osteomyelitis. The report highlights the critical role of advanced neuroimaging, particularly MRI, in the diagnosis and management of this condition. It underscores the importance of recognizing atypical presentations of Gradenigo's syndrome and the effectiveness of imaging-guided conservative treatment strategies in pediatric otological cases.

Unusual presentation of acute otomastoiditis with petrositis.

The anatomical relationships of the middle ear, the mastoid air cells, the temporal bone and intracranial structures can lead to invasive infections. Acute mastoiditis is the most common intratemporal complication of acute otitis media. Timely management includes antimicrobial therapy, imaging including ultrasound and/or computed tomography, surgical consultation and intervention. There are insufficient data to provide an evidence-based diagnostic tool for acute mastoiditis. Clinical, laboratory and microbiological differences between children with simple and complicated mastoiditis will be explored after case presentation of a 5-year-old boy with fever and a tender, soft-tissue swelling over the left zygomatic arch.

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 a triad (otorrhea, abducens nerve palsy, and pain in the trigeminal nerve distribution) of clinical findings that are caused by contiguous spread of petrous apicitis to the nearby neurovascular structures. Petrous apicitis is usually secondary to otitis media but atypical etiologies and absence of the classical triad pose a diagnostic challenge for physicians. We report a rare case of GS in an afebrile 55-year-old male who presented with unilateral headache, dysphagia and hoarseness (IX and X cranial nerve involvement), and diplopia with lateral gaze palsy (VI nerve involvement) in the absence of trigeminal neuralgia or a history of otitis media. Magnetic Resonance Imaging (MRI) revealed hyperintense lesions in the right petrous apex indicating petrous apicitis, the hallmark of GS. Prompt initiation of broad-spectrum antibiotics led to a marked improvement in dysphagia and voice quality on the 4th post-admission day, and complete resolution of symptoms by the end of the fourth week. This shows that GS can present even in the absence of clinically apparent ear infection and cranial nerve palsies may not be limited to the V and VI nerve in all cases. Physicians should be aware of such atypical manifestations as prompt radiological assessment followed by early antibiotics can prevent life-threatening complications from developing.

Cranial complications of otitis media with paralysis of the contralateral sixth cranial pair in pediatrics / [Complicaciones de la otitis media con parálisis del sexto par craneal contralateral en pediatría].

Otitis media is a frequent infection during childhood. Complications may be present in up to 4 of 100 children including serious neurological complications, particularly in developing countries. We report the case of a 9-year-old girl with no disease history who presented with otitis media, otorrhea, intracranial hypertension syndrome, and paralysis of the VI cranial nerve contralateral to the lesion. A computed tomography scan of the skull and a brain magnetic resonance imaging revealed chronic otomastoiditis, petrous apicitis, and thrombosis of the transverse and sigmoid sinus, the jugular bulb, and the right internal jugular vein. She received antibiotics and surgical treatment. This case shows the spectrum of intra and extracranial complications associated with acute otitis media in the antibiotic era. The physical examination allows early identification of intracranial hypertension with signs such as papilledema and sixth contralateral nerve palsy as an unusual finding.

La otitis media es una infección frecuente en la infancia, la cual puede producir complicaciones, incluidas las neurológicas graves, en cuatro de cada 100 niños en países en desarrollo. Se presenta el caso de una niña de nueve años sin antecedentes de enfermedad que consultó por otitis media derecha, otorrea, síndrome de hipertensión intracraneal y parálisis del VI nervio craneal contralateral a la lesión. La tomografía computarizada de cráneo y la resonancia magnética cerebral revelaron otomastoiditis crónica, apicitis petrosa, y rombosis de los senos transverso y sigmoide, el bulbo yugular y la vena yugular interna derecha. Recibió tratamiento antibiótico y quirúrgico. Este caso refleja el espectro de complicaciones intracraneales y extracraneales asociadas con la otitis media aguda en la era antibiótica. El examen físico permite la detección precoz de la hipertensión intracraneal, con signos como el papiledema y la parálisis del VI par contralateral como hallazgo inusual.

Gradenigo's syndrome in a four-year-old patient: a rare diagnosis in the modern antibiotic era.

OBJECTIVE: This study gives details of a rare case of petrous apicitis that presented as Gradenigo's syndrome and was managed surgically. METHOD: This study presents a case report and review of the literature. RESULTS: A four-year-old female was admitted for failure to thrive following recent sinusitis. Physical examination was positive for right sided facial pain, photophobia and right abducens nerve palsy. Subsequent magnetic resonance imaging revealed a 1.3 × 1.7 × 1.4 cm abscess encompassing the right Meckel's cave. A computed tomography scan showed petrous apicitis and otomastoiditis, confirming Gradenigo's syndrome. The patient was taken to the operating theatre for right intact canal wall mastoidectomy with myringotomy and tube placement. She was discharged on six weeks of ceftriaxone administered by a peripherally inserted central catheter line. At a two-week post-operative visit, she showed notable improvement in neuropathic symptoms. CONCLUSION: This study presents a rare case of petrous apicitis managed surgically without the need for a craniotomy or transcochlear procedure.

Internal carotid artery aneurysm in skull base osteomyelitis: does the pattern of cranial nerve involvement matter?

OBJECTIVE: Carotid artery aneurysm is a potentially fatal complication of skull base osteomyelitis. It is important to know the warning signs for this complication, as early diagnosis is of great importance. This report aimed to determine whether the pattern of cranial nerve involvement may predict the occurrence of aneurysm involving the internal carotid artery in skull base osteomyelitis. METHODS: Two diabetic patients with skull base osteomyelitis were incidentally diagnosed with pseudo-aneurysm of the petrous internal carotid artery on follow-up magnetic resonance imaging. They presented with lower cranial nerve palsy; however, facial nerve function was almost preserved in both cases. Computed tomography angiography confirmed aneurysms at the junction of the horizontal and vertical segments of the petrous carotid artery. RESULTS: Internal carotid artery trapping was conducted using coil embolisation. Post-coiling magnetic resonance imaging demonstrated no procedure-related complications. Regular follow up has demonstrated that patients' symptoms are improving. CONCLUSION: One should be mindful of this potentially fatal complication in skull base osteomyelitis patients with lower cranial nerve palsies, with or without facial nerve involvement, especially in the presence of intracranial thromboembolic events or Horner's syndrome.

The changing face of petrous apicitis-a 40-year experience.

OBJECTIVES/HYPOTHESIS: Petrous apicitis (PA) is a rare complication of otitis media. Gradenigo syndrome, with the classic triad of otitis, deep pain, and abducens paralysis, is rarer still. The objective of this study was to determine if clinical presentation and management has changed over time. STUDY DESIGN: Retrospective chart review. METHODS: Forty-four patients with PA over a 40-year period were studied. Symptoms, signs, and management outcomes were studied. Historical review, surgical anatomy and approaches, pathology, and microbiology, and an illustrative case are included as appendices. RESULTS: The classical Gradenigo triad of retro-orbital pain, otitis, and abducens palsy occurred in only six of 44 patients (13.6%). Over the 40-year observation period, those needing surgery has decreased. CONCLUSIONS: Antibiotics remain the primary treatment modality. Surgery is reserved for cases failing to respond to antibiotics. One of the 44 patients in this series died of his disease. Diagnosis and management algorithms based on these observations are suggested. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:195-201, 2018.

Acute Otitis Media-Induced Gradenigo Syndrome, a Dramatic Response to Intravenous Antibiotic.

INTRODUCTION: Petrositis is a rare but severe complication of acute otitis media and mastoiditis. Despite efficient antibiotic therapy, there are still reports of both intratemporal and intracranial complications of otitis media with the potential risk of high morbidity and mortality. Petrositis has traditionally been treated with surgery, but recent advances in imaging, with improved antibiotic treatment, allow more conservative management. CASE REPORT: In this case report we describe the clinical course and treatment of a 33-year-old man with petrous apicitis who presented with severe otalgia, retro-orbital pain, and sixth cranial nerve palsy Gradenigo syndrome. Our patient showed a dramatic response to intravenous antibiotics only, without need for any surgical intervention, even myringotomy. CONCLUSION: It seems that early detection and management of this syndrome before development of other intratemporal or intracranial complications may prevent the need for surgical intervention.

The Forgotten Syndrome? Four Cases of Gradenigo's Syndrome and a Review of the Literature.

BACKGROUND: Gradenigo's Syndrome (GS) is defined as the clinical triad of acute otitis media, ipsilateral sixth nerve palsy, and pain in the distribution of the first and the second branches of the fifth nerve. The purpose of this study is to review the literature and report 4 cases of GS. METHODS: The study is a retrospective case series and a review of the literature. Four consecutive patients (aged 5-70 years) treated by otolaryngologists and ophthalmologists for GS in the Capital region of Denmark from 2003 to 2015 are presented. Diagnosis is based on the clinical triad, and in 3 of 4 patients, neuroimaging supports the diagnosis. Follow-up was continued until both the sixth nerve palsy and the ear infection had resolved. Diagnostic work-up and treatment profile are described. RESULTS: In 3 of our 4 reported patients, the presentation of GS was classic with a history of acute otitis media and ipsilateral sixth nerve palsy. One case presented as a chronic case with a sixth nerve palsy secondary to chronic suppurative otitis media (CSOM), with a relapse 6 years later. CONCLUSION: GS is a rare and potentially life-threatening complication to otitis media. GS can present in an acute and chronic form, and should be a differential diagnosis in the workup of unexplained sixth nerve palsy.

Complicaciones de la otitis media con parálisis del sexto par craneal contralateral en pediatría / Cranial complications of otitis media with paralysis of the contralateral sixth cranial pair in pediatrics

Resumen. La otitis media es una infección frecuente en la infancia, la cual puede producir complicaciones, incluidas las neurológicas graves, en cuatro de cada 100 niños en países en desarrollo. Se presenta el caso de una niña de nueve años sin antecedentes de enfermedad que consultó por otitis media derecha, otorrea, síndrome de hipertensión intracraneal y parálisis del VI nervio craneal contralateral a la lesión. La tomografía computarizada de cráneo y la resonancia magnética cerebral revelaron otomastoiditis crónica, apicitis petrosa, y trombosis de los senos transverso y sigmoide, el bulbo yugular y la vena yugular interna derecha. Recibió tratamiento antibiótico y quirúrgico. Este caso refleja el espectro de complicaciones intracraneales y extracraneales asociadas con la otitis media aguda en la era antibiótica. El examen físico permite la detección precoz de la hipertensión intracraneal, con signos como el papiledema y la parálisis del VI par contralateral como hallazgo inusual.

Abstract. Otitis media is a frequent infection during childhood. Complications may be present in up to 4 of 100 children including serious neurological complications, particularly in developing countries. We report the case of a 9-year-old girl with no disease history who presented with otitis media, otorrhea, intracranial hypertension syndrome, and paralysis of the VI cranial nerve contralateral to the lesion. A computed tomography scan of the skull and a brain magnetic resonance imaging revealed chronic otomastoiditis, petrous apicitis, and thrombosis of the transverse and sigmoid sinus, the jugular bulb, and the right internal jugular vein. She received antibiotics and surgical treatment. This case shows the spectrum of intra and extracranial complications associated with acute otitis media in the antibiotic era. The physical examination allows early identification of intracranial hypertension with signs such as papilledema and sixth contralateral nerve palsy as an unusual finding.

Gradenigo syndrome: unusual consequence of otitis media.

INTRODUCTION: In 1904, Giuseppe Gradenigo published his case series on the triad of ipsilateral abducens nerve palsy, facial pain in the trigeminal nerve distribution, and suppurative otitis media, which would subsequently be referred to as Gradenigo syndrome. CASE REPORT: Our patient was a 36-year-old female, 23 weeks pregnant, with a 6-day history of right-sided otalgia and hearing loss and a 4-day history of purulent otorrhea, who presented with severe, holocephalic headache, meningeal signs, fever, photophobia, and mental status decline. Lumbar puncture yielded a white blood cell count of 1,559 cells/mm(3) with 95% polymorphonuclear leukocytes, a red blood cell count of 111 cells/mm(3), a protein level of 61 mg/dl, and a glucose level of <40 mg/dl. Cerebrospinal fluid Gram stain showed Gram-positive diplococci, which were subsequently identified as Streptococcus pneumoniae and treated with ceftriaxone. On the second hospital day, she developed horizontal diplopia due to right abducens nerve palsy and right mydriasis. Both symptoms resolved on the third hospital day. Erosion of temporal bone and opacification of mastoid air cells was shown on CT scan. A CT venogram showed an irregularity of the left transverse and superior sagittal sinuses. She was treated with enoxaparin for possible sinus thrombosis. DISCUSSION: This case demonstrates rare but serious sequelae of otitis media and Gradenigo syndrome. Holocephalic headache from meningitis masked trigeminal pain. Involvement of the ipsilateral petrous apex and surrounding structures on imaging and clinical improvement with antibiotic treatment supports Gradenigo syndrome over intracranial hypertension due to venous sinus thrombosis as the cause of the abducens nerve palsy.

Síndrome de Gradenigo: una complicación poco frecuente de la otitis media aguda / Gradenigo syndrome: a rare complication of acute otitis media

El síndrome de Gradenigo consiste en una tríada clínica dada por otitis media aguda, parálisis unilateral del VI par craneano y dolor retroorbitario ipsilateral. Se atribuye a una petrositis apical aguda, complicación evolutiva de una infección del oído medio. La disponibilidad, el acceso y el uso adecuado de la terapia antibiótica han contribuido a una disminución de la frecuencia de estas complicaciones intratemporales o intracraneales de elevado riesgo de morbimortalidad. El tratamiento de la petrositis aguda ha evolucionado, desde la cirugía radical en la era preantibiótica, al tratamiento médico y cirugía menor combinados, en los últimos años. La oftalmoplejia externa plantea diagnósticos diferenciales con otras entidades clínicas: traumatismos, neoplasias, hipertensión endocraneana y procesos infecciosos intracraneales, como trombosis del seno venoso lateral, abscesos intracraneales epi y subdurales. En esta comunicación se jerarquiza el reconocimiento oportuno de las manifestaciones clínicas de esta complicación poco frecuente con el objetivo de sensibilizar a los profesionales para su abordaje diagnóstico y terapéutico oportuno y adecuado.

The Gradenigo syndrome consists in a clinical triad of acute otitis media, unilateral paralysis of the VI cranial nerve and ipsilateral retroorbital pain. It is attributed to an acute apical petrositis by evolutionary complication from an infection of the middle ear. The availability, the access and adequate use of antibiotic therapy have contributed to decrease the frequency of this intratemporal or intracranial complications with high risk of morbidity and mortality. The treatment of acute petrositis has evolved from radical surgery in the pre-antibiotic era, to medical treatment and minor surgery combined, in recent years. The external ophthalmoplegia raises differential diagnosis with other clinical entities: trauma, neoplasms, endocranial hypertension and intracranial infections like venus thrombosis of the lateral sinus, epi and subdural abscesses. In this communication we rank the early recognition of the clinical manifestations of this rare complication to sensitize the professionals for its diagnostic and therapeutic approach timely and adequate.

Gradenigo's Syndrome: Beyond the Classical Triad of Diplopia, Facial Pain and Otorrhea.

We report a case of a non-Hodgkin's lymphoma in a young woman presenting with an abdominal mass and an unusual instance of cranial nerve palsies mimicking Gradenigo's syndrome. This condition is characterized by a triad of otorrhea, facial pain and diplopia, related to otitis media in the pre-antibiotic era. Incomplete and atypical clinical features of Gradenigo's syndrome have been described and noninfectious causes may mimic this condition. Careful clinical history and physical examination, including neuroimaging, are necessary to make a differential diagnosis.