A BRIEF HISTORY AND SUMMARY OF GRANDENIGO - LANNOIS (TRIAD) SYNDROME IN THE ENT CONTEXT.

1. GRADENIGO SYNDROME
CONDITION REVIEW
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

2. GRADENIGO (– LANNOIS SYNDROME)
• First described in 1904/7 by “The one
great Italian Otologist” Count
Proffessor Giuseppe Gradenigo
• (some include Maurice Lannois)
• Gradenigo and Dorello (who descried
Derello’s canal) had extended
disagreement over the process leading
to the symptoms causing the classic
triad
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

3. GRADENIGO SYNDROME
• Petrous Apicitis / Apical Petrousitis
• Part of Skull Base Osteomyelitis
• Acute or Chronic course
• Often Insidious onset – subtle signs
• Triad of Symptoms:
1. Active Chronic Otitis Media with
Otorrhoea
2. Trigeminal neuralgia – Boring Pain in V1
(&V2)
3. Abducens Palsy
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

4. CONSIDER ANATOMY
• At superior petrous tip lies the trigeminal
ganglion
• Irritation to ganglion explains deep facial
pain in some patients
• The petroclinoid ligament extends from
the tip to the clinoid
• Abducens nerve travels just below the
petroclinoid ligament in the Dorello canal
(fibrous bony canal)
• Inflammation extending into this area
causing the Triad:
• lateral rectus (CN VI) palsy, retroorbital
pain, and otorrhea
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

5. EPIDEMIOLOGY
• Used to be common before ABx with
high mortality
• Now, rare but still deadly!
• Mostly single case reports
• Retrospective review of petrous apicitis
cases (Gadre et al 2018) over a 40-year
period
• 6 out of 44 patients with the condition
(13.6%) had Gradenigo syndrome
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

6. AETIOLOGY
• Organisms – typically Pseudomonas
get trapped in complex air cell system –
inflammation causes mechanical
blockage
• Infection spread is via;
1. Pneumatised air cells
2. Vascular channels
3. Along fascial planes
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

7. POSSIBLE SEQUALAE
• Meningitis
• Intracranial abscess
• Spread into skull base - involving IX, X,
XI cranial nerves – Jugular foramen
syndrome (Vernet’s syndrome)
• Prevertebral/parapharyngeal abscess
• Spread to sympathetic plexus around
carotid sheath
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

8. WORK UP
• Bloods – FBC, CUE, ESR, CRP
• Tissue – Histology
• Pus – MCS, GXP, TB Culture
• CSF - Lumbar Puncture
• CT Scan
• Mastoid opacification
• Petrous apex opacification
• Bony erosion within apex
• Cavernous sinus enhancement
• Better for bone avaluation
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

9. WORK UP
• MRI
• More sensitive for soft tissue
• T1 fluid signal (low to intermediate)
• T2 fluid signal (hyperintense)
• T1 C+ (Gd): peripheral enhancement
• Dura thickening and signs of cavernous
sinus thrombosis
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

10. TREATMENT
• Conservative first
• Medical Mx
• Local & Parenteral Abx
• Consider Rx for other symptoms –
vertigo, pain, etc
• ABx:
• Ceftriaxone – penetration and BBB
crossing
• Metronidazole - anaerobes
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

11. TREATMENT
Surgical Mx
• For non-responders or unstable
• If develop complication
• Transmastoid approach
• Posterior Apex
• via sinodural angle, subarcuate or post
SCC air cells tract
• Anterior Apex
• Hypotympanic-subcochlear approach
• Tract below post SCC and jug bulb
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

12. TREATMENT
Surgical Mx
• Posterior Apex cont..
• Complete petrous apicectomy (or
modified version)
• Middle cranial fossa approach
• Circumferential petrousectomy
• Medial Apex
• Transsphenoidal endoscopic
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

13. POST OPERATIVE TX
• Require prolonged post-op Abx
• If Osteomyelitis – 6 weeks
of IV ABX
• Follow up MRI or CT
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

14. OUTCOME AND PROGNOSIS
• PreABx era = Death
• ABx = much better outcomes
• Many only conservative Rx
• Rare nowadays – small case series
• ABx + Surgery >> Abx only
• Hearing preservation or recovery quite
good
• IV ABx first line – surgery if needed
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN

15. THANK YOU
11 April 2023
DEPARTMENT OF OTOLARYNGOLOGY, TYGEREBERG HOSPITAL, CAPE TOWN