Gradenigo's syndrome presenting as IX and X cranial nerve palsy without clinically apparent ear infection: A case report and review of literature

Abstract

Gradenigo's syndrome (GS) is a triad (otorrhea, abducens nerve palsy, and pain in the trigeminal nerve distribution) of clinical findings that are caused by contiguous spread of petrous apicitis to the nearby neurovascular structures. Petrous apicitis is usually secondary to otitis media but atypical etiologies and absence of the classical triad pose a diagnostic challenge for physicians. We report a rare case of GS in an afebrile 55-year-old male who presented with unilateral headache, dysphagia and hoarseness (IX and X cranial nerve involvement), and diplopia with lateral gaze palsy (VI nerve involvement) in the absence of trigeminal neuralgia or a history of otitis media. Magnetic Resonance Imaging (MRI) revealed hyperintense lesions in the right petrous apex indicating petrous apicitis, the hallmark of GS. Prompt initiation of broad-spectrum antibiotics led to a marked improvement in dysphagia and voice quality on the 4th post-admission day, and complete resolution of symptoms by the end of the fourth week. This shows that GS can present even in the absence of clinically apparent ear infection and cranial nerve palsies may not be limited to the V and VI nerve in all cases. Physicians should be aware of such atypical manifestations as prompt radiological assessment followed by early antibiotics can prevent life-threatening complications from developing.

Keywords: Case report; Cranial nerve palsies; Gradinego's syndrome, otitis media; Otorhinolaryngologic diseases; Petrositis.

Fig. 1

CT Brain (plain) shows suspicion of right sided petrous apicitis and otitis media.

Fig. 2

(A) MRI T1-Weighted image showing hypointense right petrous apex as compared to the left. (B) On enhanced axial T1-Weighted MRI image, prominent enhancement is seen on right petrous apex. There is also mild dural contrast enhancement in the temporal region without evidence of leptomeningeal involvement or parenchymal involvement. (C) MRI T2-Weighted image showing hyperintense right petrous apex in comparison with the contralateral petrous apex.

Fig. 3

Timeline of events.