P 1139. Gradenigo’s Syndrome: Two New Case Studies

Background: Gradenigo’s syndrome is characterized by the triad of pain in the trigeminal nerve, ipsilateral diplopia caused by abducens nerve paralysis and a purulent otitis media.

In 1904, Guiseppe Gradenigo described the symptom complex. It is caused by a purulent otitis with spreading to the mastoid bone into the petrous apex of the temporal bone with possible abscess formation. Complications include meningitis, extra- and intradural abscesses, and sinus vein thrombosis. An impairment of other cranial nerves (IX–XI) is also described. The incidence of this serious disease has become extremely rare since the treatment with potent antibiotics. The diagnosis is often made late. We describe two patients, who were treated at our clinic in the first quarter of 2018, to show that the diagnosis is still present today and that symptoms must be considered (Table 1).

Case Studies:

1. A 10-year-old girl comes with acute diplopia, an abducens nerve paralysis left, and otitis media left. Magnetic resonance imaging (MRI) shows a left temporal bone abscess.

2. A 5-year-old girl develops right-side pain in the trigeminal area, followed by diplopia and an abducens nerve paralysis on the right side. Clinically, there is also an otitis media on the right side and the MRI showed a mastoiditis on the right side. Liquor shows elevated levels of leukocyte, protein, and lactate. The glucose in the liquor is reduced in relation to blood sugar.

A pathogenic agent could not be detected in both patients.

Therapeutically, a mastoidectomy was done in both patients. In the case of the 10-year-old female patient, a complete regression of clinical symptoms and abscess was seen under treatment with intravenous cefotaxime and clindamycin for 6 weeks. The 5-year-old female patient also shows a complete regression of the clinical symptoms and a regression of the abscess on the clivus after treatment with vancomycin and meropenem intravenously after 1.5 weeks. She is currently still in treatment.

Conclusion: It is important to recognize the symptom triad of a Gradenigo’s syndrome with pain in the trigeminal region, diplopia caused by abducens nerve paralysis and a purulent otitis media and to initiate an MRI from the head. More difficult is the diagnosis of atypical symptoms. The Gradenigo’s syndrome is thus an important differential diagnosis in newly occurring abducens nerve paralysis. Because of the serious complications, a broad antibiotic therapy and usually a rapid ENT-specialist intervention is required.

No conflict of interest has been declared by the author(s).