Gradenigo’s Syndrome Conservative Management Remains an Option Despite Complications: A Case Report

To the Editors: Gradenigo’s syndrome (GS) consists of a clinical triad of (1) otitis media; (2) pain in the regions innervated by the first and second branches of the trigeminal nerve; and (3) ipsilateral abducens nerve palsy manifesting as eye squint.1 This constellation of symptoms is caused by inflammation of the petrous apex of the temporal bone causing petrous apicitis and critical surrounding structures namely the trigeminal nerve ganglion and the abducens nerve secondary to medial extension of otitis media infection. We report successful treatment of a child with complicated GS treated conservatively. A 5-year-old male child, presented with fever and right ear pain for 4 days followed by sudden onset right eye worsening squinting. His physical examination was remarkable for right eye squint and was noted to cover his right eye using his right hand whenever he wanted to walk or be examined, however, no signs of otitis media were appreciated. Increased inflammatory markers, such as C-reactive protein 331 and erythrocyte sedimentation rate 95, were found in his labs. Magnetic resonance imaging showed near complete opacification of the right mastoid air cells, middle ear cavity, and right petrous apex with corresponding diffusion restriction and heterogeneous enhancement on postcontrast imaging. These inflammatory changes were noted to extend to the right cavernous sinus with the involvement of Mickle’s cave. A second epidural abscess collection was also seen along the anterior border of the petrous apex. The distal cervical, petrous, and cavernous segments of the right carotid artery were attenuated, with a thickened enhancing wall denoting vasculitis, and preserved flow within as seen in Figure 1. A multispecialty team assessment including neurosurgery, ENT, and infectious diseases decided to manage him conservatively with right ear myringotomy plus grommet insertion only and to complete 6 weeks of ceftriaxone and metronidazole at meningitic doses via home care. Enoxaparin was started to prevent clot formation and was continued until the resolution of his symptoms. Clinical and inflammatory markers improvement was evident near the end of the antibiotics course when a follow-up magnetic resonance imaging brain done on an outpatient basis showed complete resolution of the anterior mesial temporal extra-axial infective collection.FIGURE 1.: Axial T2 (A) and contrast-enhanced T1 (B) magnetic resonance images demonstrate right mastoid, middle ear, and petrous apex opacification and enhancement. In addition, there is a right extra-axial abscess collection (white arrow) showing corresponding diffusion restriction on the diffusion-weighted image (C). The cavernous sinus is involved and Meckel’s cave (black arrowhead) appears smaller and displaced.GS is a specific and interesting entity that is not uncommonly encountered in children and can be challenging to approach and treat. Historically, GS has been managed surgically, however, there has been a shift towards conservative management as delineated in our patient that is guided by a multispecialty team approach.2 Presentation can be incomplete3 by missing one of the criteria such as in our case despite his complicated infection. The role of neuroimaging is paramount in GS where magnetic resonance imaging is superior to computed tomography in delineating the full extent of the petrous apicitis infection and its associated complications and can be unutilized for follow-up.4 Antibiotic therapy using a local antibiogram is essential especially if an organism was isolated in their ear culture. Further, transition to oral therapy can be facilitated unless a complicated intracranial extension is of concern, however, there is no consensus for treatment duration in literature.5