Viswanath V.1, Manish Gupta2
Giuseppe Gradenigo described a triad of retro orbital
pain, paralysis of the sixth cranial nerve and persistent
otorrhea.5 Hence, the syndrome is known as Gradenigo’s
syndrome. Due to the advent of antibiotics, very few
complete triads can be found these days. Here, a rare case
of petrositis complicated by chronic otitis media of a 19-yearold
male is presented.
Petrositis is a rare complication of otitis media. And
further rare are those presenting with triad of Gradenigo’s
syndrome (retro-orbital pain, abducens nerve palsy and
persistent otorrhea) due to advent of antibiotics.
In literature, only around 48 publications are present in
otorhinolaryngology. Gradenigo’s syndrome was first
described in 1904 by Giuseppe Gradenigo.5 It was commonly
associated with acute otitis media, with few cases reported
in chronic otitis media and with cholesteatoma.6,7
Most cases of petrous apicitis occur in well-developed air
cell systems extending into the petrous apex.1,2 Review of
previously published case reports of Gradenigo’s syndrome
have shown that between one week to three months is the
usual time course to develop sixth (abducens) cranial nerve
palsy from the onset of acute otitis media (AOM).6,7 This is
not surprising, since the petrous apex is the summit of the
pyramid-shaped petrosum, of which the middle ear and the
mastoid form the base. The inflammatory process spreads
from the base to the top of the pyramid, extending along the
strings of pneumatized cells from the mastoid towards the
petrous apex.8 However, when chronic suppurative otitis
media (CSOM) is present in Gradenigo’s syndrome, sixth
(abducens) cranial nerve palsy may develop up to three
years later.6
In addition to the triad symptoms of Gradenigo
syndrome, petrous apicitis has different type of
presentations like ipsilateral facial paralysis due to 7th
cranial nerve affection, defective cranial nerves VIII, IX, and
X are found, along with vertigo and sensorineural hearing
loss due to result of labyrinthine involvement of the inner
ear.4 In our case also, mild sensorineural hearing loss at the
time of presentation suggested labyrinthitis. In Gradenigo’s
original case series of 57 patients, more than half of the
cases did not followed the classical triad.5
Enhancing the drainage and giving prolonged
intravenous antibiotics is the established line of treatment,
for petrositis.2 Most authors advocate surgery, due to
potentially fatal complications, if left untreated. Chole and
Donald stated that aggressive surgical drainage is indicated
when petrous apicitis is diagnosed.2 Watkyn-Thomas
reported that petrositis is curable by adequate mastoid
operation.9 Hendersot presented a middle fossa approach
for the treatment of petrous apicitis.10
But, due to complex anatomy of the region and difficulty
to work around labyrinth and carotid vessel, the complete
excision of petrous apex air cells is impossible. Thus, when
recent reports advocated conservative therapy with highdose
broad-spectrum antibiotics and less aggressive surgical
