Facial Neuritis as a Manifestation of Gradenigo's Syndrome

Abstract

Gradenigo's syndrome (GS) is a rare, acquired syndrome caused by middle ear infections or mastoiditis. It is identified by the triad of otorrhea due to otitis media (OM), retro-orbital pain in the region innervated by the first and second divisions of the trigeminal nerve, and diplopia as a result of cranial nerve (CN) VI palsy. As a result of extension of the inflammation, the facial nerve (VII) may also be affected. GS has a poor prognosis unless promptly diagnosed and treated. Herein, we report the clinical and radiological findings observed in two children diagnosed with chronic suppurative OM, mastoiditis, and facial neuritis. Both were medically managed as cases of GS with high-dose intravenous antibiotic and full recovery was achieved a few weeks after discharge. There was no need for any surgical intervention. This case report illustrates the importance of early recognition, diagnosis, and treatment of this treatable syndrome using antibiotics to prevent subsequent fatal complications and further need for surgical intervention.

Keywords

Gradenigo's syndrome - acute otitis media - petrositis - Bell's palsy - abducens palsy

Note

Written informed consent for the publication of this case report was obtained from the parents of the patients.

Authors' Contributions

A.Y.K. managed the patients and wrote the manuscript as the main author. O.Y.K. share in patient's management, critically reviewed, and helped organize the manuscript. All authors read and approved the final manuscript.

Publication History

Received: 12 February 2021

Accepted: 25 March 2021

Article published online:
19 June 2021

• References

• 1 Gradenigo G. Uber die Paralyse des n. abduzens bei otitis (About paralysis of the nervus abducens in otitis). Arch Ohrenheilunde 1907; 774: 149-187
• 2 Hafidh MA, Keogh I, Walsh RM, Walsh M, Rawluk D. Otogenic intracranial complications. a 7-year retrospective review. Am J Otolaryngol 2006; 27 (06) 390-395
• 3 Chole RA, Donald PJ. Petrous apicitis. Clinical considerations. Ann Otol Rhinol Laryngol 1983; 92 (6 Pt 1): 544-551
• 4 Norwood VF, Haller JS. Gradenigo syndrome as presenting sign of T-cell lymphoma. Pediatr Neurol 1989; 5 (06) 377-380
• 5 Gore MR. Gradenigo's syndrome: a review. Ann Med Health Sci Res 2018; 8: 220-224
• 6 Motamed M, Kalan A. Gradenigo's syndrome. Postgrad Med J 2000; 76 (899) 559-560
• 7 Gibier L, Darrouzet V, Franco-Vidal V. Gradenigo syndrome without acute otitis media. Pediatr Neurol 2009; 41 (03) 215-219
• 8 Finkelstein Y, Marcus N, Mosseri R, Bar-Sever Z, Garty BZ. Streptococcus acidominimus infection in a child causing Gradenigo syndrome. Int J Pediatr Otorhinolaryngol 2003; 67 (07) 815-817
• 9 Hanci F, Türay S, Bayraktar Z, Kabakuş N. Childhood facial palsy: etiologic factors and clinical findings, an observational retrospective study. J Child Neurol 2019; 34 (14) 907-912
• 10 Özkale Y, Erol İ, Saygı S, Yılmaz İ. Overview of pediatric peripheral facial nerve paralysis: analysis of 40 patients. J Child Neurol 2015; 30 (02) 193-199
• 11 Schiavetto RR, Haber DM, Cancian LR. et al. Gradenigo's syndrome as a first manifestation of rhabdomyosarcoma. Int Arch Otorhinolaryngol 2009; 13: 326-330
• 12 Adams RD, Victor M, Ropper AH. Principles of Neurology. 6th ed.. The McGraw-Hill Companies; 1997: 1376-1377
• 13 Azarmina M, Azarmina H. The six syndromes of the sixth cranial nerve. J Ophthalmic Vis Res 2013; 8 (02) 160-171
• 14 Sweeney PJ, Hanson MR. Cranial neuropathies. In: Bradley WG, Daroff RB, Fenichel G, Jankovic J, Mazziotta J. eds. Neurology in Clinical Practice. Philadelphia: Elsevier, Inc; 2012: 1754
• 15 Jensen PV, Hansen MS, Møller MN, Saunte JP. The forgotten syndrome? Four cases of Gradenigo's syndrome and a review of the literature. Strabismus 2016; 24 (01) 21-27
• 16 Pedroso JL, de Aquino CC, Abrahão A. et al. Gradenigo's syndrome: beyond the classical triad of diplopia, facial pain and otorrhea. Case Rep Neurol 2011; 3 (01) 45-47
• 17 Jackler RK, Parker DA. Radiographic differential diagnosis of petrous apex lesions. Am J Otol 1992; 13 (06) 561-574
• 18 Jacobsen CL, Bruhn MA, Yavarian Y, Gaihede ML. Mastoiditis and Gradenigo's Syndrome with anaerobic bacteria. BMC Ear Nose Throat Disord 2012; 12: 10
• 19 Luntz M, Brodsky A, Nusem S. et al. Acute mastoiditis--the antibiotic era: a multicenter study. Int J Pediatr Otorhinolaryngol 2001; 57 (01) 1-9
• 20 Burston BJ, Pretorius PM, Ramsden JD. Gradenigo's syndrome: successful conservative treatment in adult and paediatric patients. J Laryngol Otol 2005; 119 (04) 325-329
• 21 Minotti AM, Kountakis SE. Management of abducens palsy in patients with petrositis. Ann Otol Rhinol Laryngol 1999; 108 (09) 897-902