Emergency radiologic approach to mastoid air cell fluid.

Mastoid air cell fluid is a commonly seen, but often dismissed finding. Given the location of the mastoid portion of the temporal bone and its location adjacent to vital structures, a careful evaluation is important for the emergency radiologist. While occasionally benign, fluid within the mastoid air cells can be an early sign of more severe pathology, and familiarity of regional anatomy allows for early identification of disease spread. This article describes the important anatomy, the common pathologies, and a radiologic approach to assessing the mastoid air cells in order to guide referring clinicians.

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: 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.

Insights into Gradenigo syndrome: Case presentation and review.

Gradenigo syndrome (GS) is characterized by a triad of clinical features: abducens nerve palsy, retro-orbital pain, and otorrhea, arising as a complication of suppurative otitis media. Herein, we present a case of GS in a 15-year-old male patient, secondary to left otitis media. The patient exhibited fever, otorrhea, accompanied by diplopia, retrobulbar pain, and headache. Imaging studies demonstrated petrous bone destruction and inflammatory changes with opacification of petrous bone, mastoid cells and surrounding structures, confirming the diagnosis of GS. Treatment included intravenous antibiotics and anticoagulants, resulting in the resolution of symptoms and radiological improvement. GS, though rare, warrants prompt recognition and appropriate management to prevent severe complications. Diagnostic imaging plays a crucial role in evaluation, and treatment often involves prolonged antibiotic therapy and, in severe cases, surgical intervention. Understanding the clinical presentation and management strategies is essential for clinicians encountering this condition.

A Case of Gradenigo's Syndrome in an Elderly Patient.

Gradenigo's syndrome (GS) presents with the classical triad of otitis media, facial pain, and abducens nerve palsy as a complication of petrous apicitis. However, in the era of increased antibiotic use, complications of petrous apicitis have become infrequent and cases of GS are not frequently seen in clinical practice. We present the case of a 76-year-old man with uncontrolled diabetes mellitus presented with a two-month history of worsening right-sided headache, right-sided facial pain and weakness, along with dysphagia, hearing loss, and right otalgia with intermittent otorrhea following a right upper molar extraction. Imaging identified the inflammatory changes and indications of petrous apicitis. Although GS has become quite rare in recent years, this case highlights the importance of the responsible use of antibiotics in treating a seemingly innocuous infection.

Neurosurgical Intervention in the Treatment of Gradenigo Syndrome: A Case Report.

Gradenigo syndrome comprises a clinical triad: retro-orbital pain, sixth cranial nerve palsy, and purulent otorrhea. This clinical syndrome often arises secondary to petrous apicitis, which is an infection of the petrous apex that may result from the contiguous spread of infection from the ear or mastoid. This syndrome is very rare, and based on the existing literature, the initial approach for treatment involves long-term administration of IV antibiotics, which may resolve the underlying infection related to petrous apicitis, mastoiditis, and/or otitis media. In this case, the patient, a 69-year-old male, had a progression of several symptoms, including recurrent headaches, diplopia, hearing loss, and dysphagia, despite long-term antibiotic therapy and a prior mastoidectomy. Thus, the neurosurgical team decided to intervene via anterior petrous bone resection via the Kawase approach, which unfortunately did not result in the resolution of the patient's symptoms. The patient continued to have symptoms of Gradenigo syndrome, including sixth cranial nerve palsy and was subsequently referred to outpatient follow-up for further management. In this report, we present the patient's case and a brief review of the literature concerning various treatment modalities for Gradenigo syndrome.

Transmastoid and Transtemporal Drainage of Petrous Apicitis with Otitis Media.

BACKGROUND: Petrous apicitis (PA) is a serious infection involving the apical portion of the petrous temporal bone. The classic triad of purulent otorrhea, ipsilateral abducens nerve palsy and retroorbital pain is rarely seen due to early detection and widespread use of antibiotics. Medical management is the primary treatment modality with surgery reserved for cases of recalcitrant petrous apex abscess. METHODS AND RESULTS: We presented a case of PA with previously untreated otitis media. After multidisciplinary evaluation, the patient was initially treated with intravenous antibiotics followed by drainage of the abscess using a combined transmastoid and middle cranial fossa (MCF) approach. The patient recovered well with no recurrence of the infection based on imaging and symptoms. DISCUSSION: While a variety of different surgical approaches can be used in treatment of PA, we recommend the MCF approach in cases where access to the anterior petrous apex may be challenging via transcanal or transmastoid approach.

An unusual case of acute otitis media resulting in Gradenigo syndrome: CT and MRI findings.

With the widespread use of antibiotics, Gradenigo syndrome is a rare complication of acute otitis media (AOM) and acute mastoiditis. It is an uncommon form of petrous apicitis and can be life-threatening. We report the case of a 14-year-old female with unresolved AOM, who developed otorrhea, ipsilateral headaches, diplopia and raised inflammatory markers. Magnetic Resonance Imaging (MRI) demonstrated features of petrous apicitis and confirmed the suspicion of Gradenigo syndrome. The objective of this clinical case report is to highlight this unusual syndrome together with its radiological appearance to improve its diagnosis and management.

Case Report: Petrous Apicitis and Otogenic Thrombosis of the Cavernous Sinus in a 10-Year-Old Boy.

Background: Petrous apicitis and cavernous sinus thrombosis are exceedingly rare complications of acute otitis media with only few reported cases in the post-antibiotic era. Especially in children, the appropriate management is a subject of controversy. Case Presentation: We report the case of a 10-year-old boy who presented to the emergency department with left-sided otalgia, otorrhea, and hearing loss, accompanied by somnolence and high spiking fevers. CT and MRI revealed partially obstructed mastoid air cells including a pneumatized petrous apex. Furthermore, thrombosis of the cavernous sinus and vasculitis of the internal carotid artery on the left side were present. The patient was treated with antibiotics for 6 weeks and anticoagulant therapy for 3 months. Follow-up carried out 3 months post-admission showed complete recanalization of the cavernous sinus on MRI and fatigue as the only remaining symptom. Conclusion: A complicated otitis media with petrous apicitis and cavernous sinus thrombosis in a child can in some cases be managed without a surgical intervention.

Steroid-Responsive Gradenigo's Syndrome Mimicking Subdural Hematoma.

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.

Conservative management of petrous apex abscess and Gradenigo's syndrome in a diabetic patient: Case report and literature review.

The case reported evidences the possibility of nonsurgical treatment in patients with abscesses located in regions difficult to reach surgically due to surgical limitations or possible sequelae related to surgical procedure.

How well do we know Gradenigo? A comprehensive literature review and proposal for novel diagnostic categories of Gradenigo's syndrome.

Gradenigo's Syndrome is a rare complication of otitis media and/or mastoiditis resulting in inflammation of the petrous apex of the temporal bone. Here, we highlight an interesting case from our institution, summarize available pediatric cases from the past fifty years to provide an updated diagnostic categorization for this rare condition with confusing nomenclature, and suggest guidance for diagnosis and management.

Delayed diagnosed Gradenigo's syndrome associated with acute otitis media.

Gradenigo's syndrome presents as a triad of retroorbital pain, ipsilateral abducens palsy, and purulent otorrhea. If the otologic pathologies in Gradenigo's syndrome go unnoticed, the condition could be misdiagnosed with neurological diseases because of retroorbital pain and abducens palsy. Treatment of Gradenigo's syndrome remains controversial. Although some reports state that long-term antibiotic treatment is sufficient, we recommended that management ought to be guided on a case-by-case basis depending on patient and disease factors. Herein, we report a delayed diagnosed pediatric case of Gradenigo's syndrome associated with acute otitis media that was treated with ventilation tube insertion.

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.

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.