Post-tympanoplasty Gradenigo Syndrome - Don’t Panic

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Post-tympanoplasty
Gradenigo Syndrome
- Don’t Panic 13
Department of Otorhinolaryngology,
Head & Neck Surgery,
All India Institute of Medical Sciences,
New Delhi, India
Introduction
The tympanoplasty is a valid treatment
to address pathology of tympanic membrane
and middle ear.1,2 The preoperative assessment
includes detailed history and complete
examination with necessary investigations.
Any previous history of surgery and chronic
medical problem should be documented. The
complications associated with tympanoplasty
depend on destruction of vital structures
caused by disease or accidently by surgery.
3 Postoperative infection can occur due to
infected middle ear at the time of surgery and
poor intrasurgical aseptic technique.4
We are presenting here an interesting case
of vertigo with left lateral rectus palsy post
tympanoplasty. This case also suggests that
proper radiological examination with expert
assessment is essential to identify and confirm
the diagnosis.
Case Presentation
A 30-year-old female presented with
Hitesh Verma

Complicated Cases in Vertigo and Dizziness
130
history of left ear discharge since 10-15 years. The discharge was episodic, with
mucoid, non foul smelling, profuse in amount and without bleeding. There was
no relevant personal and family history. The examination showed large central
perforation in left tympanic membrane. The diagnosis of safe chronic suppurative
otitis media (CSOM) was made and the patient underwent tympanoplasty under
local anesthesia. The intra-operative and early postoperative period was uneventful.
The patient was sent home on the same day. The patient developed vertigo, and
diplopia on seventh postoperative day. The clinical examination showed left 6th
cranial nerve palsy. High resolution computerized tomography (HRCT) was done.
The HRCT of temporal bone revealed soft tissue density in epitympanum and
hypotympanum, mastoid air cells and petrous apex region with the possibility of
cholesteatoma. The HRCT also showed a well defined extra axial lesion measuring
18×10 mm in left petrous apex and cerebro-pontine angle (CP angle). The differential
diagnoses for CP angle lesion were kept as schwannoma and aneurysm. Contrast
magnetic resonance imaging (CEMRI) was further advised. The CEMRI revealed
hyperintense mass in middle ear cleft. The MRI also showed separate hyperintense
mass at petrous apex and CP angle. The diagnoses were kept as schwannoma and
cholesteatoma for pertruos apex lesion and residual choleasteatoma of middle ear
cleft lesion.
The patient then came to (All India Institute of Medical Sciences) AIIMS ENT
OPD with history of vertigo, diplopia and one month history of tympanoplasty. The
vertigo and diplopia were the presenting symptoms. The vertigo was continuous,
with nausea and occasional vomiting. The clinical examination showed left lateral
rectus palsy with nystagmus (Fig. 1). The fast component of nystagmus was toward
left ear suggestive of irritation of ipsilateral labyrinth. The local examination showed
Figure 1
Clinical
photography
showing left
lateral rectus
palsy.

Post-tympanoplasty Gradenigo Syndrome - Don’t Panic 131
well healed post auricular scar with purulent, foul smelling discharge coming out
from left external auditory canal. The examination of ear after cleaning of discharge
revealed congested graft with pulsatile discharge coming out from perforation in
antro-inferior part of graft. The HRCT available with patient showed soft tissue
density in middle ear and mastoid air cells without air cells erosion suggestive of
acute infection. The separate soft tissue density was also seen in the region of petrous
apex and CP angle (Fig. 2).
Figure 2 HRCT temopral bone (axial cut) revealing soft tissue density in left
petrous apex and cerebropontine angle.
Investigations
The pus was sent for gram staining, culture and sensitivity. The culture report
showed gram-positive bacteria Staphylococcus aureus and sensitivity report favored
the use of ciprofloxacin and gentamycin. The previous HRCT temporal bone and
MRI was discussed with radiologist in radio-conference clinic. They advised repeat
MRI as scans were not clear. The final MRI showed 2.4x1.4 cm T2W intermediate
and T1W hyperintense lesion in prepontine region causing compression in inferior
pons. The lesion was restricted on DW1 with no enhancement on post contrast

Complicated Cases in Vertigo and Dizziness
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study. T2W hyperintense and T1w hypointensity was noted in left petrous apex, CP
angle and mastoid air cell system (Fig. 3). The CISS sequences and MR spectroscopy
were done (Fig. 3). The final impression was congenital neuroenteric cyst in
prepontine region with acute mastoiditis and petrositis.
Figure 3 MRI showing hyperintense lesion in left petrous apex, CP angle and
mastoid air cell system with separately hyperintense lesion in prepontine region.
Figure 4
Clinical
photograph
showing
recovery of 6th
cranial nerve.

Post-tympanoplasty Gradenigo Syndrome - Don’t Panic 133
Diagnosis
A possible diagnosis of Gradenigo syndrome was considered. The hypothesis
postulated was, that blood or pus collecting under the graft was extending into the
pneumatized petrous apex and CP angle via the petrous air cells. The collection of
fluid was responsible for the compression of the trigeminal ganglion and irritation of
the abducent (6th cranial) nerve at petrous apex and CP angle region.
Management
The broad spectrum oral antibiotics with local antibiotic ear drops and
antivertiginous drugs were given for six weeks. Antiemetics were advised SOS.
Follow-up
The patient was called for follow-up after two days to see the response with
prescribed antibiotics and the report of culture sensitivity of the pus of external
auditory canal. The patient showed marked improvement in reduction of vertigo
but abducent cranial nerve palsy was persisting. The antibiotics were changed as
advised by culture and sensitivity report. On follow-up visit at two weeks, vertigo
had stopped completely and symptoms of 6th nerve palsy were significantly reduced.
The lateral rectus palsy had also recovered at the follow-up at six weeks.
Discussion
The petrous apex communicates with the middle ear cleft via pneumatized
anterior and posterior petrous cells.5 These cells are found in 15-30% of cases.
Tympanoplasty is reconstruction of hearing mechanism with or without repair of
tympanic membrane. The procedure can be done under general or local anesthesia.
The selection of anesthesia is dependent on several factors such as patient profile,
surgeon experience and hospital facilities etc. The causes of postoperative surgical
infection usually are patient or surgical characteristics. The surgical factors for
nosocomial infection include; duration of surgery, site of surgery, aseptic precautions
and amount of blood loss.6 In tympanoplasty, duration of surgery usually varies
between 1-2 hrs and the amount of blood loss is minimal. The patient factors
include age, sex, socioeconomic status, comorbid illness, etc.7 Poor personal hygiene
is a major factor for occurrence of perforation in tympanic membrane. The intra-
operative factors include shaving, use of disinfectant, ventilation of operation theatre
and use of proper drapes.7
Petrositis can lead to meningitis, intracranial abscess, cranial nerve palsy,
labyrinthitis and death if they are unrecognized or treated incompletely.8 The thin
dura mater in relation with the 6th cranial nerve and trigeminal ganglion at petrous
apex is another reason for involvement of these structures, the inflammation and
involvement thereby presenting as Gradenigo syndrome. The Gradenigo syndrome

Complicated Cases in Vertigo and Dizziness
134
includes 6th nerve palsy, retroorbital pain and otorrhea.8,9 Post antibiotic era, very
few patients present with all the symptoms of the triad9 as was seen in our case.
The interval between middle ear infection and onset of Gradenigo Syndrome varies
between one week to a few months. The infection extends to the petrous apex from
the middle ear cleft via the pneumatized petrous cells.10,11
Earlier the treatment for petrositis, Gradenigo syndrome was aggressive surgical
management via transmastoid or middle cranial fossa approach12,13 but recent studies
advocate conservative management with broad spectrum antibiotics9,10,14,15 as was
done by us in this case.
Why this case was chosen?
The various factors that need to be considered to avoid complication in
such cases include surgery that needs to be done with proper asepsis.
Targeted antibiotic regimen should be administered.
Care should be taken to avoid Intra-operative bleeding extending to
petrous apex and CP angle via petrous cells which can later present with
compression of 6th cranial nerve.
1. Detail history and complete examination is required in all cases.
2. Surgery should be done in dry ear when pathology is safe.
3. Gram staining and culture sensitivity is required if the discharge continues
with usual treatment.
4. Proper aseptic condition and experience is required even for minor surgeries.
5. Expert opinion and complete evaluation are must in complicated cases
which includes surgeon and radiologist.
Key Points
References
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