Rachel Boixadera

Hull University Teaching Hospitals NHS Trust, UK

Abstract Title:

Incomplete Gradenigo’s Syndrome with Cavernous Sinus Thrombosis

Research Interests:

Gradenigo’s syndrome is a triad of otitis media, abducens nerve palsy and pain along the trigeminal nerve distribution. A three-year-old boy presented with acute otitis media and ipsilateral diplopia. Prior to his presentation to hospital, he experienced fever and otalgia for a month, during which he completed two courses of oral amoxicillin. He was on the 99th centile for height and weight and resisted several cannulation attempts. Due to his lack of intravenous access, the proposed initial management was adapted following discussion with the wider multi-disciplinary team. He received intramuscular ceftriaxone instead of intravenous broad-spectrum antibiotics and underwent CT head instead of MRI due to inability to safely sedate him without intravenous access. CT demonstrated petrous apicitis with ipsilateral mastoid and middle air cell opacification. Grommet and peripherally-inserted central catheter insertion were performed under anaesthesia, facilitating subsequent imaging and provision of antibiotic therapy. MRI confirmed his diagnosis of incomplete Gradenigo’s syndrome but also demonstrated a cavernous sinus thrombosis not reported in the prior CT scan. He received a one-week course of intravenous meropenem stepped down to six and a half weeks of ceftriaxone for treatment of the apicitis. The cavernous sinus thrombosis resolved following completion of sixteen days of tinzaparin followed by a three-month course of rivaroxaban. No causative organism was isolated in blood or pus cultures. He was followed up by the paediatric team three months after his initial presentation and reached a full recovery without visual or auditory sequelae. This case emphasises the need for MRI imaging for increased diagnostic sensitivity. Multi-disciplinary and inter-specialty collaboration were essential to providing patient-centred management. Key words Abducens palsy Gradenigo’s syndrome Cavernous sinus thrombosis Acute otitis media