Double Vision and Ear Discharge in a 14-Year-Old Girl

Olugbemiga Jegede, MD; Walid Abuhammour, MD


December 09, 2015

Treatment of Gradenigo syndrome must be initiated immediately. The underlying infection must be addressed in order to prevent further spread, complications, or permanent abducens nerve injury. The advent of the antibiotic era has facilitated the conservative management of a select cohort of patients with apical petrositis. It is now generally advocated that patients be treated with high-dose, broad-spectrum antibiotics and less-aggressive surgical procedures.[2]

Surgical treatment involves a minimum of infectious decompression with myringotomy and ventilation tube placement. Tympanocentesis should be performed to allow for culture-directed intravenous antibiotic therapy. In patients with cranial nerve palsies, steroids have been used to speed recovery by reducing inflammation, edema, and nerve compression.[4]

The MRI of the patient in this case showed fluid collection in the left middle ear, mastoid air cells, and the petrous apex, which is consistent with the diagnosis of apical petrositis. This finding, in conjunction with retro-orbital pain, otorrhea, and ipsilateral sixth nerve palsies, led to the final diagnosis of Gradenigo syndrome. Her blood and CSF cultures were negative; however, the middle ear fluid culture showed Stenotrophomonas maltophilia sensitive to trimethoprim-sulfamethoxazole. Her antibiotic prescription was changed from meropenem to intravenous trimethoprim-sulfamethoxazole, and 6 days of intravenous dexamethasone was added to her regimen.

The patient started to show improvement on the third day of trimethoprim-sulfamethoxazole and steroid therapy. The sixth and seventh nerve palsies improved slowly, and a decrease in the ear discharge, headache, and left orbital pain were noted. She received both intravenous and oral trimethoprim-sulfamethoxazole for a total of 6 weeks, and she continued physiotherapy for the facial nerve palsy. A follow-up examination showed full recovery, and a repeat MRI a few months later showed full resolution.

Gradenigo syndrome should be considered in patients with suppurative otitis media who present with orbital/retro-orbital pain and/or cranial nerve palsies, especially palsy of the sixth nerve. Prompt otolaryngology consultation and initiation of antibiotic therapy are important in curtailing the serious morbidity resulting from this condition.


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