Fusobacterium necrophorum an Underrecognized Cause of Petrous Apicitis Presenting with Gradenigo Syndrome: A Case Report.

BACKGROUND With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more uncommon is Gradenigo syndrome (GS), a result of PA, characterized by a triad of otitis media or purulent otorrhea, pain within the regions innervated by the first and second division of the trigeminal nerve, and ipsilateral abducens nerve palsy. Recent literature has demonstrated increasing reports of Fusobacterium necrophorum isolated in cases of GS. CASE REPORT A 21-year-old man presented with otalgia, reduced hearing, and severe headache. Examination revealed right-sided purulent otorrhea, anesthesia within the trigeminal nerve distribution, and an ipsilateral abducens nerve palsy. F. necrophorum was isolated from an ear swab and a blood culture. Computed tomography and magnetic resonance imaging (MRI) demonstrated otomastoiditis, PA, cavernous sinus thrombosis, and severe stenosis of the petrous internal carotid artery. He was treated with intravenous benzylpenicillin, underwent a mastoidectomy and insertion of a ventilation tube, and was started on a 3-month course of dabigatran. Interval MRI showed improved internal carotid artery caliber, persistent petrous apex inflammation, and normal appearance of both cavernous sinuses. Follow-up clinical review noted persistent abducens and trigeminal nerve dysfunction. CONCLUSIONS We identified 190 cases of PA; of these, 80 presented with the classic Gradenigo triad. Fusobacterium sp. were cultured in 10% of GS cases, making them the most frequent isolates. Due to the fastidious nature of F. necrophorum, it may be underrepresented in the historical literature, and we recommend that empiric antibiotics cover anaerobic organisms.

Gradenigo Syndrome in a 6-Year-Old Boy with Acute Otitis Media: A Case Report.

Gradenigo Syndrome (GS) is not a common intracranial complication of acute otitis media infections that needs proper diagnosis and management. This case report presents a 6-year-old child diagnosed with unilateral headache, right eye diplopia, and right abducens nerve palsy. MRI and cranial nerve examination facilitate the confirmation of GS. The patient was treated with proper antibiotics and showed good outcomes. This case report highlights the importance of early detection and understanding of the clinical picture associated with GS, which have a crucial role in achieving desired outcomes and avoiding serious complications.

Acute Bacterial Meningitis and Petrous Apicitis in a Child with Aplasia Cutis Congenita: A Case Report.

Petrous apicitis and acute bacterial meningitis are uncommon in the present antibiotic era. The diagnosis of petrous apicitis is seldom considered unless there is cranial nerve palsy. A young child with aplasia cutis congenita presented with acute bacterial meningitis and an incidental opacified left mastoid in brain imaging. During the course, fever persisted, and high-resolution temporal bone imaging showed rapid progression to coalescent mastoiditis, petrous apicitis with erosions of tegmen tympani, and petrous apex. Other findings included bony dehiscences and thinning of left calvaria. Tympanomastoid exploration showed herniated brain and cerebrospinal fluid leak through tegmen tympani, which was closed with temporalis fascia graft. Herein, we report a rare presentation of petrous and tegmen erosion along with aplasia cutis congenita and discuss the challenges in diagnosis and management.

Diplopia in a Child: Gradenigo Syndrome Is an Unforgettable Disease.

Gradenigo syndrome is a clinical triad of abducens nerve palsy, retro-orbital pain (trigeminal ganglionitis), and chronic otorrhea (otitis media). The etiology of Gradenigo syndrome results from apical petrositis secondary to suppurative otitis media. Although apical petrositis has gradually become uncommon in modern society due to the widespread use of antibiotics, Gradenigo syndrome should be considered in the differential diagnosis of a child's diplopia.

[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.

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.

Petrous Apicitis: A Systematic Review and Case Presentation.

INTRODUCTION: Petrous apicitis (PA) is a rare but dangerous complication of acute otitis media. The objective of this study is to present a case of PA and systematically review the existing literature on PA to characterize clinical presentation, diagnosis, management, and outcomes in the antibiotic era. METHODS: A comprehensive search from 1983 to June 1, 2020, of PubMed, MEDLINE, Cochrane Library, and EmBase databases was conducted. Studies with clinical data regarding patients with PA were included. Non-English literature or studies with insufficient individual patient data were excluded. Sixty-seven studies were included with a total of 134 patients. RESULTS: A total of 67 articles were found to meet criteria for inclusion. The mean age of presentation was 33 years. Recent acute otitis media was reported in 78 patients (58.2%). Only 3 patients (2.2%) were immunocompromised, and 8 patients (6.0%) had a history of diabetes. Gradenigo's triad of abducens palsy, otorrhea, and retro-orbital or facial pain was reported in 28 patients (20.9%); however, these presenting symptoms were common individually (51.5%, 48.5%, and 64.2%, respectively). Hearing loss (35.8%), facial weakness (17.9%), and vertigo (7.5%) were also reported.The most frequently cultured pathogen was Pseudomonas (34.2%), followed by Streptococcus and Staphylococcus. All 134 patients underwent imaging, with computed tomography being the most frequently used modality (56.0%). Nearly all patients received antibiotic therapy (95.6%), with 91 (67.9%) undergoing surgery ranging from myringotomy (26.9%) to petrosectomy (25.4%). Five patients (5.7%) died because of complications related to PA. Mean follow-up was 11.0 months. CONCLUSIONS: Petrous apicitis has a variable presentation with potential for severe morbidity. Mortality rates are low, and presentation with Gradenigo's triad is uncommon. Appropriate medical management with surgical drainage can avoid long-term sequelae.

Unrecognized Petrous Apicitis as a Cause of Long- Lasting Headache in a 5-Year-Old Child: Case Report.

Petrous apicitis (PA) is an extremely rare complication of otitis media (OM), one of the most common infections in children. We describe a case of PA in a 5-year-old girl who remained misdiagnosed for a time because of its presentation mainly as a headache and the late onset of the characteristic symptoms. Our patient received an initial diagnosis of non-suppurative OM, but after a course of antibiotic treatment, her headache persisted. During the following 2 months, she was examined numerous times by neurologists as well as by ear, nose, and throat and pediatric specialists, all of whom concluded that there was no organic cause of the headache. Finally, after the patient suddenly developed signs of abducens nerve palsy, new computed tomography (CT) findings revealed severe temporal bone destruction caused by an inflammatory process. This case report shows the importance of a thorough approach to identify headaches in children. Additional attention must be applied when examining a child with prolonged symptoms of headaches that do not subside with standard therapy.

Rapid Recovery of Cranial Nerve Deficits After Anterior Petrosal (Kawase) Approach for Medically Refractory Petrous Apicitis.

BACKGROUND: The mainstay treatment for petrous apicitis (Gradenigo's syndrome) is medical management with antibiotics, steroids, and placement of pressure equalization tubes. The role for surgery is limited as second-line treatment if conservative methods have failed. CASE DESCRIPTION: We report 2 cases of medically refractory petrous apicitis presenting with progressive cranial neuropathies who underwent petrous apex resection and debridement via an anterior petrosal (Kawase) approach. Both patients had improvement of their preoperative cranial nerve deficits within 24-48 hours of surgery, that previously did not improve after 2 weeks of medical management. CONCLUSIONS: To our knowledge, the use of the Kawase approach for petrous apicitis has not been previously reported. In addition, we postulate that surgical intervention can potentially result in quicker recovery of preexisting cranial nerve deficits in medically refractory petrous apicitis. This raises the potential role of earlier surgical intervention.

A child with Gradenigo syndrome presenting with meningism: a case report.

BACKGROUND: The symptoms of meningitis which include fever, headache, photophobia and irritability along with abducens nerve palsy pose a diagnostic dilemma requiring urgent attention. Here we report how such a dilemma was methodically and sequentially resolved using anatomical knowledge supported by neuroimaging and the eventual diagnosis of Gradenigo syndrome was made. CASE PRESENTATION: A 6-year-old previously healthy boy from Sri Lanka presented with high grade fever, headache, photophobia and left eye pain for 10 days and diplopia for 2 days duration. Neurological examination was unremarkable except for left sided abducens nerve palsy. He had high inflammatory markers and white blood cell count. A tentative differential diagnosis of acute bacterial meningitis complicated by cerebral oedema, acute hydrocephalus or cerebral abscess was made. However, non-contrast CT brain, cerebrospinal fluid analysis and electroencephalogram were normal leading to a diagnostic dilemma. MRI brain with contrast performed 3 days later due to limited resources revealed left mastoiditis extending to petrous temporal bone confirming Gradenigo syndrome. CONCLUSION: This case report highlights the importance of a thorough physical examination in children presenting with unrelated neurological symptoms and signs. Unilateral abducens nerve palsy raises the suspicion of increased intracranial pressure and neuroimaging is vital in diagnostic uncertainties. Gradenigo syndrome emphasises the importance of incorporating anatomical knowledge into clinical practice.

Headache in Petrous Apicitis: A Case Report of Chronic Migraine-like Headache Due to Peripheral Pathology.

OBJECTIVE: To report a case of petrous apicitis that manifested as chronic migraine without aura and to discuss the pathophysiological mechanisms behind this presentation. BACKGROUND: Petrous apicitis is a rare complication of acute otitis media with varied clinical presentations that stem from the close proximity of the petrous apex to numerous neurovascular structures. Headache is among the common symptoms of petrous apicitis. METHODS: A case of new onset headache in the setting of petrous apicitis with symptomatic response to antibiotic therapy was reported. We provided a brief review of peripheral pathophysiological mechanisms of migraine and correlated to mechanism of headache in petrous apicitis. RESULTS: A 65-year-old man with chronic otitis externa/media presented with ongoing headache fulfilling International Classification of Headache Disorders 3rd edition (ICHD-3) criteria for chronic migraine without aura that persisted despite undergoing right mastoidectomy and tympanoplasty with multiple courses of oral antibiotic therapy for his chronic otitis. MRI brain revealed petrous apicitis, otomastoiditis, and clival osteomyelitis. His imaging findings improved and his migraine-like headache completely resolved after treatment with a prolonged course of antibiotics. CONCLUSIONS: Petrous apicitis can present as a headache with features of migraine, and in this case in particular, as chronic migraine without aura. The pathophysiological mechanisms that may underlie the generation of migraine-like headache in petrous apicitis may include the activation of nociceptive fibers within the periosteum of the petrous apex and clivus whose cell bodies originate in the trigeminal ganglion and upper cervical dorsal root ganglia. By treating the peripheral pathology, resolution of the headache may be achieved.

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.

Sudden Diplopia at a Pediatric Emergency Department: A Case of Gradenigo Syndrome in a Child.

OBJECTIVE: Otitis media, facial pain in trigeminal region, and ipsilateral abducens nerve palsy clinically define Gradenigo syndrome, a rare but serious complication of suppurative middle ear infection. Radiological investigation is required to confirm petrous apex involvement and to exclude further consequences as sinus thrombosis, meningitis, and intracranial abscess. METHODS/RESULTS: We report the case of an 8-year-old child referred to our emergency department for recurrent headache and sudden strabismus. Clinical evidence of suppurative otitis media raised the suspicion for Gradenigo syndrome, definitively confirmed at computed tomography and magnetic resonance imaging scans. Conservative treatment alone enabled complete clinical and radiological remission, without long-term sequelae. CONCLUSIONS: Despite being a rare condition, Gradenigo syndrome should be taken into account as potential differential diagnosis in children referred to emergency department for recurrent headache and strabismus. An accurate anamnesis to document recent ear infection is mandatory to orientate the diagnosis and focus radiological investigations. Early recognition and timely intervention may allow conservative management to succeed, avoiding the need for surgery and serious sequelae.

Acute otitis media associated with Gradenigo syndrome and transverse sinus thrombosis: a case report.

Gradenigo syndrome is associated with middle ear infection that extends to the petrous apex, leading to pain at the innervation site of the ophthalmic and maxillary branches of the trigeminal nerve and the development of abducens nerve palsy. Cerebral venous sinus thrombosis is a serious neurological complication of otitis media and occurs secondary to spread of the infection to the underlying bone. We herein report a pediatric case of otitis media associated with Gradenigo syndrome and ipsilateral sigmoid-transverse sinus thrombosis with magnetic resonance imaging findings.

Recurrent petrositis due to nasopharyngeal carcinoma in an adult patient: Gradenigo's syndrome.

The early diagnosis of very rare nasopharyngeal carcinoma (NPC) is so difficult, to surrounded by structures such as the orbital skull base. With the invasion of the disease, the symptoms are manifested in different ways so that it may be confusion and delay in diagnosis and treatment in this situation. Including otological symptoms (serous otitis media), Gradenigo's syndrome is a rare clinical condition. The majority of published cases involve children, and the most common etiology is otitis media. We report a case of a diabetic man who presented with repeating Gradenigo's syndrome symptoms due to NPC.

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

BACKGROUND 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.

A fatal case of Gradenigo's syndrome in Zimbabwe and the Danish-Zimbabwean ENT collaboration.

As a part of a bilateral educational exchange program two Danish ENT residents were invited to Zimbabwe in 2015. During this exchange a 9-year-old girl was admitted due to complications to acute otitis media (AOM). She developed Gradenigo's syndrome and later on a brain abscess leading to a fatal outcome. Life threatening complications to AOM are rare in developed countries today but are still a challenge in developing countries. We put forward this case from a developing country to bring focus to the fact that a fatal outcome is the consequence if specialist treatment is not accessible.