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C ASE R E P O R T Open Access
Mastoiditis and Gradenigo’s Syndrome with
anaerobic bacteria
Chris Ladefoged Jacobsen
1*
, Mikkel Attermann Bruhn
1
, Yousef Yavarian
2
and Michael L Gaihede
1
Abstract
Background: Gradenigo’s syndrome is a rare disease, which is characterized by the triad of the following
conditions: suppurative otitis media, pain in the distribution of the first and the second division of trigeminal
nerve, and abducens nerve palsy. The full triad may often not be present, but can develop if the condition is not
treated correctly.
Case presentation: We report a case of a 3-year-old girl, who presented with fever and left-sided acute otitis
media. She developed acute mastoiditis, which was initially treated by intravenous antibiotics, ventilation tube
insertion and cortical mastoidectomy. After 6 days the clinical picture was complicated by development of
left-sided abducens palsy. MRI-scanning showed osteomyelitis within the petro-mastoid complex, and a hyper
intense signal of the adjacent meninges. Microb iological investigations showed Staphylococcus aureus and
Fusobacterium necrophorum. She was treated successfully with intravenous broad-spectrum antibiotic therapy with
anaerobic coverage. After 8 weeks of follow-u p there was no sign of recurrent infection or abducens palsy.
Conclusion: Gradenigo’s syndrome is a rare, but life-threatening complication to middle ear infection. It is most
commonly caused by aerobic micro organisms, but anaerobic microorganisms may also be found why anaerobic
coverage should be considered when determining the antibiotic treatment.
Keywords: Gradenigo’s syndrome, Acute mastoiditis, Apical petrositis, Acute otitis media, Abducens palsy,
Fusobacterium necrophorum
Background
Gradenigo’s Syndrome (GS) is a clinical triad of the
following conditions; otitis media, pain in the distribu-
tion of the first and second division of the trigeminal
nerve and ipsilateral abducens palsy. It was originally
described in 1907 by Guiseppe Gradenigo [1]. Before the
antibiotic era it was not uncommonly seen as a compli-
cation to acute otitis media (AOM) and mastoiditis. The
symptoms occur as the infection spreads to the petrous
apex of the temporal bone, where the sixth cranial nerve
and the trigeminal ganglion are in close proximity only
separated by the dura mater. The involvement of the
sixth cranial nerve is seen as a reaction caused by the ad-
jacent inflammation, as the nerve passes through
Dorello´s canal under the petroclinoid ligament [2].
The full triad of symptoms in GS may not always be
present. For instance, the absence of abducens palsy does
not rule out apical petrositis. Radiologic evaluation by
computed tomography (CT) and magnetic resonance im-
aging (MRI) are helpful tools in the diagnosis and man-
agement of GS, as well as they may exclude differential
diagnoses like septic sinus thrombosis or other non-
infectious entities [3,4]. With the widespread use of anti-
biotics the incidence of apical petrositis is now rare, re-
portedly two per 100,000 children with acute otitis
media [5].
We report a case of AOM complicated by mastoiditis
and apical petrositis presenting as Gradenigo’s syndrome.
Case presentation
A 3-year-old healthy girl with no prior medical history was
admitted to the pediatric department after 4 days with a
high fever (39–40.4°C; 102.9-104°F) and left-sided otor-
rhea. Upon admission the child was in poor condition,
dehydrated, pyretic and pale. Physical examination showed
* Correspondence: chlaj@rn.dk
1
Department of Otolaryngology, Head and Neck Surgery, Aalborg Hospital -
Aarhus University Hospital, Aalborg, Denmark
Full list of author information is available at the end of the article
© 2012 Jacobsen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Jacobsen et al. BMC Ear, Nose and Throat Disorders 2012, 12:10
http://www.biomedcentral.com/1472-6815/12/10
left mastoid tenderness with retroauricular erythema,
edema and fluctuation. Furthermore, examination of the
eyes revealed normal movements and reflexes; there were
no meningeal signs, changes in consciousness or other
neurological findings. No cervical lymph nodes were
enlarged. Initial blood samples showed a C-reactive pro-
tein of 256 mg/L and intravenous antibiotic treatment
with benzyl penicillin was initiated.
The child was transferred to our ORL department,
where otomicroscopy showed edema of the external audi-
tory canal and a bulging, hyperemic tympanic membrane.
These findings led to surgical drainage of the abscess
under general anesthesia and insertion of a ventilation
tube into the left tympanic membrane. Mucopurulent ma-
terial from the abscess and the middle ear was sent for
microbiological examination. The day after the operation
the child showed signs of improvement with remission of
fever as well as the retroauricular edema and erythema,
and the anorexia diminished. However, later the same day,
fever relapsed (39.0°C; 102,2°F), as well as progression of
the erythema and swelling around the incision. Because of
the rapid deterioration acute mastoidectomy and drainage
were performed.
During the following days continuous clinical improve-
ment was registered. Six days after the operation the
child had problems maintaining balance, and the parents
noticed that she had developed a slight strabismus. No
headache or involvement of the trigeminal nerve were
found. Physical examination showed normal visus on
both eyes, but discrete left-sided papillar edema and ab-
ducens palsy (Figure 1).
In order to exclude the possibility of sinus thrombosis,
an MRI scanning was performed. This demonstrated
osteomyelitis within the petro-mastoid complex (Figures 2
and 3); further, thickening and enhancement of the adja-
cent meninges were demonstrated (Figure 4), whereas
there were no signs of sinus thrombosis. Finally, no intra-
cranial abscesses were found after contrast injection.
The pus culture isolated from the mastoid abscess
revealed growth of Staphylococcus aureus sensitive for
dicloxacillin and cefuroxime, but resistant to penicillin and
Fusobacterium necrophorum was demonstrated sensitive
to metronidazole and penicillin. The child was discharged
after a total of 20 days of intravenous antibiotics as a com-
bination of cefuroxime and metronidazole. By the time of
8 weeks clinical follow-up examination there were no signs
of recurrent infection or abducens palsy.
Conclusions
GS as a result of petrositis is rarely seen after the introduc-
tion and widespread use of antibiotics. It remains, how-
ever, a serious and potentially fatal complication to AOM
and acute mastoiditis.
Whereas the pneumatisation of the mastoid cells of
the temporal bone is almost universal, the pneumatisa-
tion of the petrous apex varies and is only found in one
third of adult patients; in such cases it may provide a
path for AOM to spread also medially causing apical pet-
rositis [4]. In addition, this condition may also be a result
of direct extension of the infection through bony de-
struction or hematologically through venous channels
causing true osteomyelitis in the non-pneumatized areas
of the petrous bone [6]. Due to the central location of
the petrous apex, apical petrositis may rapidly develop
into severe and life threatening complications like me-
ningitis, brain abscess, lateral sinus thrombosis, empyema
Figure 1 Left-sided abducens palsy at its onset 6 days after mastoidectomy.
Jacobsen et al. BMC Ear, Nose and Throat Disorders 2012, 12:10 Page 2 of 5
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and cranial nerve palsies [4-6]. The delay between otologic
symptoms and cranial nerve involvement varies from 1 week
to 2–3 months [7]. In our case, the time between the onset
of the initial symptoms and the registration of the abducens
palsy was two weeks.
We found the causative pathogens to be Staphylococcus
aureus in combination with Fusobacterium necroforum
found in both the middle ear and the mastoid cavity.
Staphylococcus aureus are frequently found in acute mas-
toiditis (8.6 %), only surpassed by Pseudomonas aerugi-
nosa (11.8 %), Streptococcus pneumoniae (9.9 %) and
Streptococcus pyogenes (9.2 %) [8]. It has been argued that
S. aureus has a greater tendency to invade bone, since it
has been found in more ca ses with osteomyolitis [8].
Figure 2 MRI horizontal section T1 + Gadolinium. Arrows show areas with enhancement in left pars petrosa.
Figure 3 MRI coronal section T1 + Gadolinium. Arrow shows area with enhancement in left pars petrosa.
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The demonstration of Fusobacterium necrophorum
in GS is more unusual, and to our knowledge this has only
been reported in two cases previously [9,10]. Fusobacterium
necrophorum is an anaerobic, non-motile Gram-negative
rod, usually found in the oral flora, the gastro-intestinal
tract as well as the genito-urinary tract in females. It usually
does not invade mucosal surfaces in healthy individuals, but
if the host´s defence system is compromised it has been
known to cause a variety of rapidly progressing serious
infections including bacteremia; these clinical conditions
are known as necrobacillosis [11].
The demonstration of Fusobacterium necrophorum is
difficult, since the cultivation is complex and depends on
a prolonged incubation period; this may cause an under-
estimation of its clinical demonstration [12] however the
cultivation of anaerobic microorganism should be con-
sidered. Thus, when empiric antibiotical treatment is
started, it can be recommended to include both a potent
anti-staphylococcal agent as well as metronidazole to
cover anaerobic organisms.
CT scan is the first choice of imaging, since it is widely
available and has a high sensitivity for detection of
changes in bone structures including lesions in the pet-
rous apex where GS in most cases will appear [4]. Fur-
thermore it may detect the presence of intercranial
abscesses, though it is less sensitive than MRI. An MRI
is useful in evaluating the extent of the lesion of the pet-
rous apex localised on the CT scan, as well as demon-
strating meningeal involvement. Moreover, MRI is
superior in detecting intracranial complications [3,4,13].
An MRI angiography may be performed to rule out signs
of sinus thrombosis.
GS is a rare, but life-threatening complication to mid-
dle ear infection that should be taken into consideration
when atypical symptoms develop after AOM. Radio-
logical modalities such as CT and MRI should not be
delayed and CT should be regarded as first choice of im-
aging when GS is suspected. Treatment should include
drainage of the middle ear and mastoidectomy as well as
intravenous broad spectrum antibiotics. GS is most com-
monly caused by aerobic microorganisms, but it may also
be found in interaction with anaerobic microorganisms.
Due to the severity of related complications we suggest
that antibiotic treatments include anaerobic coverage.
Consent
Written consent, for publication of the clinical details
and clinical images was obtained from the parent of the
patient. A copy of the consent form is available for re-
view by the Editor of this journal.
Abbreviations
GS: Gradenigo’s Syndrome; AOM: Acute otitis media; CT: Computed
tomography; MRI: Magnetic resonance imaging.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
CJ carried out the writing of the manuscript, acquisition of informed consent
and literature research and approval of all images in the case report. MB
helped in outlining and modification of the manuscript as well as selection
and acquisition of photographs used in the case report. YY carried out the
Figure 4 MRI horizontal section T1 + Gadolinium. Arrow shows local thickening and enhancement of the dura.
Jacobsen et al. BMC Ear, Nose and Throat Disorders 2012, 12:10 Page 4 of 5
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radiological evaluation, selection and description of the MRI images and
modification and approval of the imaging section. MG supervised,
commented and helped in the revision and final approval of the manuscript.
All authors have read and approved the final manuscript.
Financial and non-financial disclosure
None.
Author details
1
Department of Otolaryngology, Head and Neck Surgery, Aalborg Hospital -
Aarhus University Hospital, Aalborg, Denmark.
2
Department of Radiology,
Aalborg Hospital - Aarhus Universi ty Hospital, Aalborg, Denmark.
Received: 26 March 2012 Accepted: 15 August 2012
Published: 14 September 2012
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doi:10.1186/1472-6815-12-10
Cite this article as: Jacobsen et al.: Mastoiditis and Gradenigo’s
Syndrome with anaerobic bacteria. BMC Ear, Nose and Throat Disorders
2012 12:10.
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