Thursday 29 March 2012

Gradenigo's syndrome MRI

Syn: Gradenigo Lannois syndrome.
A rare complication of otitis media and mastoiditis involving petrous apex of temporal bone.

Clinically characterised by triad of Ear Discharge, Diplopia, Hemifacial pain.
1  Suppurative otitis media explains ear discharge and pain.
2. Trigeminal nerve (5th CN) involvement explains Trigeminal neuralgia - pain in the distribution of the trigeminal nerve  manifest with hemicranial headache, hemi facial pain.
3. Abducens nerve (6th CN) involvement explains ipsilateral Lateral rectus palsy and Lateral gaze palsy manifest with reproducible Diplopia.

In these patients infection spread from suppurative otitis media to the petrous apex may be via pneumatised air cell tracts, through vascular channels, or as a result of direct extension through fascial planes and giving rise to apical petrositis.
Trigeminal nerve and ganglia lies very close to petrous apex separated by a dura and Abducene nerve lies medial to the trigeminal ganglion.
Extradural inflammation secondary to apical petrositis may form a soft tissue plegmon involve the above mentioned cranial nerves and give rise to symptom triad of Gradenigo’s syndrome.
Early recognition of condition is important to prevent intracranial complications like Meningitis, Intracranial abscess, Spread to skull base and involvement of IX, X, XI cranial nerves (Vernet’s syndrome), Prevertebral/parapharyngeal abscess, Spread to sympathetic plexus.

Case : A 45 yo female with left side ear discharge since 2 weeks with left sided headache and squint clinically. On examination left ear drum perforation with purulent discharge. Left lateral rectus palsy. 
Left side Mastoiditis, Otitis media and Petrositis.
An associated abnormal  adjacent enhancing soft tissue with focal dural enhancement.
The soft tissue extending in left side cavernous sinus explains left side 6th CN involvement and lateral rectus palsy, in left side Meckel's cave explains left side 5th CN involvement. 
A triad of Otitis media, left hemi cranial headache and left lateral rectus palsy consistent with Gradenigo's syndrome. 

No comments: