Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 9585  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
 :: Next article
 :: Previous article 
 :: Table of Contents
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::Related articles
 ::  Article in PDF (578 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  Discussion
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed19027    
    Printed393    
    Emailed13    
    PDF Downloaded308    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


 


 
IMAGES IN RADIOLOGY
Year : 2002  |  Volume : 48  |  Issue : 4  |  Page : 314-6

Gradenigo's syndrome: findings on computed tomography and magnetic resonance imaging.


Department of Radiodiagnosis and Imaging, Christian Medical College and Hospital, Vellore - 632 004, India., India

Correspondence Address:
L Mathew
Department of Radiodiagnosis and Imaging, Christian Medical College and Hospital, Vellore - 632 004, India.
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 12571394

Rights and PermissionsRights and Permissions



Keywords: Adult, Case Report, Child, Human, Magnetic Resonance Imaging, Male, Mastoid, pathology,Otitis Media, diagnosis,radiography,Otosclerosis, pathology,Petrous Bone, pathology,Syndrome, Tomography, X-Ray Computed,


How to cite this article:
Mathew L, Singh S, Rejee R, Varghese A M. Gradenigo's syndrome: findings on computed tomography and magnetic resonance imaging. J Postgrad Med 2002;48:314

How to cite this URL:
Mathew L, Singh S, Rejee R, Varghese A M. Gradenigo's syndrome: findings on computed tomography and magnetic resonance imaging. J Postgrad Med [serial online] 2002 [cited 2019 Nov 17];48:314. Available from: http://www.jpgmonline.com/text.asp?2002/48/4/314/68


A 25-year old man presented with history of right-sided otorrhoea for 3 weeks. It was accompanied with headache, vomiting and diplopia. On examination, this afebrile patient was noted to have ipsilateral sixth nerve palsy and a pinpoint perforation in the tympanic membrane of the right ear. The right mastoid was tender. However, there was no evidence of papilloedema or neck stiffness. The leucocyte count was 11000/ mm3 [polymorphs 73%, lymphocytes 19% and monocytes 6%] while the ESR was 87 mm at the end of 1 hour.

The computed tomography showed obliteration of the right mastoid air cells with sclerosis of the mastoid antrum and petrous bone [Figure:1A]. The external and middle ear structures also showed obliteration of normal definition. The external auditory canal was widened and a small soft tissue density area was seen around it. There was destruction of the ipsilateral petrous apex. Mildly enhancing soft tissue mass was seen indenting the adjacent pons [Figure:1B]. The mastoid antrum, the middle and inner ear structures and the brain parenchyma on the contralateral side were normal. On magnetic resonance imaging, the T2 and proton density-weighted and Fluid Attenuated Inversion Recovery (FLAIR) images showed hyperintense petrous and mastoid parts of the right temporal bones with a small ill-defined high signal intensity lesion surrounding them [Figure - 2]. The middle ear structures and the external auditory canal were also hyperintense. The pre-contrast T1-weighted images demonstrated small isointense component in the petrous apex [Figure:3A]. On post contrast imaging, the MRI showed marked heterogeneous enhancement of the involved petrous apex and surrounding meninges [Figure:3B]. The clinical, laboratory and radiological findings helped to establish the diagnosis of Gradenigo’s syndrome. The patient was treated with intravenous antibiotics [crystalline penicillin, chloramphenicol, and metronidazole]. Cortical mastoidectomy was done with exteriorisation of the cell tracts above the superior semicircular canal going towards petrous apex. No organisms were grown in the exudates from the middle ear and histopathological examination of the mastoid antrum revealed non-specific inflammatory tissue. At follow-up one month later, the patient showed clinical improvement in the form of absence of otorrhoea, healing of the tympanic membrane and improvement in the lateral rectus palsy.

Case 2

A 12-year-old boy presented with history of otorrhoea from the left ear, headache and diplopia for one month. On examination, central perforation was noted in the tympanic membrane of the left ear. Ipsilateral sixth nerve palsy was present, too. The total leucocyte count was 13,000/mm3 with 70% neutrophils, 1% band forms, 15% lymphocytes, 5% eosinophils, and 5% monocytes. The erythrocyte sedimentation rate was 45mm at the end of first hour.

The computed tomography showed sclerosis of the left mastoid antrum and petrous bone, loss of aeration of the mastoid air cells and destruction of the petrous apex with an enhancing mass around the petrous apex and the left parasellar region. On magnetic resonance imaging, T2, proton density-weighted and FLAIR images, the petrous and mastoid parts of the left temporal bone and the left middle ear structures appeared heterogeneously hyperintense [Figure - 4]. Moderately enhancing soft tissue structures were seen to surround the petrous apex and parasellar region.

He was treated with intravenous antibiotics [crystalline penicillin, chloramphenicol, and metronidazole]. The patient obtained dramatic relief from symptoms after mastoidectomy and drainage of pus from the petrous apex. He was treated with anti-tuberculous drug regime as an empirical treatment.

Discussion

Gradenigo’s syndrome, characterised by persistent otorrhoea, pain in the region innervated by the first and second divisions of the trigeminal nerve and ipsilateral abducens nerve palsy, is one of the complications of middle ear infection. CT and MRI scans provide evidence of this complication. However, there are only a few reports[1],[2],[3],[4],[5],[6] in the literature describing these findings.

Gradenigo’s syndrome consist of abducens nerve paralysis, retroorbital pain and middle ear infection. Although classically attributed to petrositis, the syndrome has also been described in association with extradural abscess, pachymeningitis overlying the petrous apex[6] and lateral sinus phlebitis.[6] It is thought that the manifestations of the syndrome result from the extension of the inflammatory process, that begins in the middle ear, to the top of the petrous part of the temporal bone.[6] The raised intracranial pressure itself is, probably due to, a combination of lateral sinus thrombosis and superior sagittal sinus obstruction. The former impedes the cranial venous outflow while the latter impedes the CSF absorption by pacchionian bodies.[6]

The CT scans demonstrate fluid-filled mastoid air cells and sclerosis of the bones and one can assess the degree of periosteal reaction and status of the middle ear structures based on CT scan findings.[2] The MRI scans are best for assessing the soft tissue lesions. These lesions appear hypointense on T1-weighted images and hyperintense on T2 weighted images and enhance following contrast.[2]

Management consists of administration of appropriate anti-microbial agents and surgical intervention. However, improvement without the administration of anti-microbial agents has also been described. McHugh et al reported a case of Gradenigo syndrome, where CT scan showed a small mass in the left IAC and MRI showed evidence of petrositis. These lesions showed marked improvement without treatment.[6] The report also underlined the utility of gadolinium enhanced MRI in identifying soft tissue inflammation and intra-osseus disease in the absence of bone destruction.[5] Complications like brain abscess have been described.[5] Homer et al,[6] reported three cases with middle ear infection and sixth nerve palsy without petrositis and raised intracranial pressure. Erosion of the malleus and incus, a loculus of gas in the sinodural angle, opacification of the left mastoid antrum and clouding of the mastoid antrum were the lesions demonstrated in these patients on the CT scan. As otitic hydrocephalus, another complication of the middle ear infection is also associated with abducens nerve palsy, neuroimaging should be employed to differentiate between these two conditions.

 
 :: References Top

1.Tutuncuogle S, Uran N, Kavas I, Ozsur T. Gradenigo’s syndrome; a case report. Pediatr Radiol 1993;23:556.   Back to cited text no. 1    
2.Murakani T, Tsubaki J, Tahara Y, Nagashima T. Gradenigo’s syndrome: CTand MRI findings. Pediatr Radiol 1996;26:684-5.  Back to cited text no. 2    
3.Minotti AM, Kountakis SE. Management of abducens palsy in patients with petrositis. Ann Otol Rhinol Laryngol 1999; 108:897-902.  Back to cited text no. 3    
4.Hananya S, Horowitz Y. Gradenigo’s syndrome and cavernous sinus thrombosis in fusobacterial acute otitis media. Harefuah 1997;133: 284-6. [Abstract]  Back to cited text no. 4    
5.McHugh K., de Silva M., Isaacs D. MRI of Petrositis in chronic granulomatous disease. Pediatr Radiol 1994;24:530-1.  Back to cited text no. 5    
6.Homer JJ, Johnson IJM, Jones NS. Middle ear infection and sixth nerve palsy. J Laryngol Otol 1996;110:872-4.  Back to cited text no. 6    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]

This article has been cited by
1 Gradenigoæs syndrome - A case report
Bidner, A., Lee, A.
ANZ Nuclear Medicine. 2008; 39(4): 2-6
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article
Online since 12th February '04
© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow