- Venus is the second planet from the Sun and has a beautiful name. It is very hot, even hotter than Mercury. - Gradenigo's syndrome is a rare complication of acute otitis media characterized by the triad of suppurative otitis media, deep facial pain, and abducens nerve palsy. It is caused by the spread of otic infection into the petrous bone. - A 6-year-old girl presented with sudden onset of diplopia following headaches and right ear pain/drainage. Examination found right abducens nerve palsy. Imaging showed infection in the right middle ear that had spread to the petrous bone. She was treated

1. Gradenigo’s Syndrome a Rare Complication of Acute Otitis Media:
Case Report and Literature Review
Supervisore: dr.Dina Alia, Sp.THT-KL,PhD
By: Seba AL-Gunaid

3.  Gradenigo's syndrome (GS) is a triad (otorrhea, abducens nerve palsy, and pain
in the trigeminal nerve distribution) caused by the spread of otic infection into
the apical part of the petrous temporal bone (petrous apicitis).
 The signs and symptoms of the disease process are often not clear, and
presentations vary enormously
 These cranial nerve dysfunctions are caused by osteitis of the petrous apex
(petrous apicitis) and are very rare complications of otitis media
 In recent years, there is an increase in the incidence of intratemporal and
intracranial complications of middle ear infection in younger children
Introduction

4.  The trigeminal nerve ganglion and the abducens nerve are separated
from the petrous apex only by dura mater therefore they are
vulnerable to any inflammatory process occurring that region.
 The inflammatory process starts in the middle ear, and spreads from
the base to the top of the petrous portion of the temporal bone,
producing several diagnostic symptoms.
Introduction

5. A 6-year-old girl, fully vaccinated, who was in a good health with no past
medical history of recurrent AOM, was admitted to the hospital for sudden onset
of diplopia following 6 days of headaches, right otalgia and otorrhea. She had been
treated with orally administered antibiotics for otitis media 3 days before the onset
of these symptoms.
At admission she had right otalgia and otorrhea, with bulging perforated
tympanic membrane. The left tympanic membrane was normal. There was no
mastoid tenderness. Her temperature was 37.7. She had no meningeal signs.
Examination of eyeball movement show right abductor nerve palsy (Figure 1).
Case Presentation

6. Case Presentation

7. Advance investigation:
 There was a normal facial motility.
 Facial pain was localized in the first and second branches of the right trigeminal
nerve.
 Ophtalmoscopy and biomicroscopy were normal.
 Audiometry was a 30 dB right side conductive hearing loss.
 Laboratory tests showed a white blood cell count of 4800/UL, a platelet count of
364000 /uL, a sedimentation rate of 40 and a C-reactive protein of 8mg/L.
 A CT scan of the brain and the petrous temporal bone showed a subtotal filling of the
right middle ear, and the cavernous sinus was clear (Figure 2).
CASE Presentation

9. She was commenced on :
 Co-amoxiclav 200mg/kg/24h IV
 Dexamethason 2mg/24h
 The patient completed 6 weeks of intravenous antibiotics and 3 weeks of oral
antibiotics, with favorable outcome.
 She made complete recovery after 9 weeks (Figure 4).
Treatment

10. Treatment

11.  Gradenigo’s syndrome is a rare but life threatening complication of AOM.
 Clinically, it is characterized by the triad of suppurative otitis media, deep facial
pain, and abducens palsy.
 Most of the Gradenigo syndrome cases that have been reported in the
literature were caused by pyogenic bacteria.
 CT scanning remains the first line investigation for possible lesions of the
petrous apex because it is more available than MRI. It is also sensitive enough in
detecting bone erosion.
 MRI is used to detect the extent of meningeal and cerebral involvement.
DISCUSSION

12.  For the treatment two associations were indicated in the literature: Ceftriaxone
50 mg/kg/24h and metronidazole 40 mg/kg/24h in association with
vancomycin for an average of 30 days, or with amikacin 3 mg/kg/24h for 3
days.
 The antibiotheray was relayed with oral amoxi clav for 3 to 4 weeks.
DISCUSSION

13.  Although it is a rare condition, Gradenigo’s syndrome remains a fatal
complication of otitis media that should be looked for and treated in order to
avoid intracranial complications such as brain abscess. CT scan and MRI
represent the top diagnosis arsenal. Conservative management is possible with
the evolution of antibiotics, and early diagnosis.
DISCUSSION

14. TELAAH KRITISI JURNAL DIAGNOSIS DINI
Pedoman Keterangan
1.Apakah metode penelitian
suatu randomized trial?
Jawaban : Tidak
Penelitian ini adalah case report
2. Apakah ada pengobatan yang
efektif untuk kelainan tersebut?
Jawaban : Ya
Dalam penelitian ini tdijelaskan
terkait pengobatan efektif tehadap
Gradenigo’s syndrome

15. TELAAH KRITISI JURNAL DIAGNOSIS DINI
Pedoman Keterangan
3. Apakah ada sesuatu hal
tersembunyi pada penyakit
tersebut yang memerlukan
screening?
Jawaban : Ya
Diagnosis awalnya Gradenigo’s
syndrome CT scan tetap menjadi
investigasi lini pertama
untuk memigakan lesi pada apeks
petrous
Apakah screening test
mempunyai angka sensitifitas
dan spesifisitas yang
tinggi?
Jawaban : Tidak
Dalam penelitian ini tidak di
sebutkan nilai hasil pemeriksaan yg
specific untuk tega diagnose

16. TELAAH KRITISI JURNAL DIAGNOSIS DINI
Pedoman Keterangan
5. Dapatkah sistem kesehatan
(skala nasional atau profesi)
selaras dengan
program screenign test
yang akan dilaksanakan?
Jawaban : Ya
screeing OMA dan pengobatan
OMA yang dini membantu untuk
menghindari komplikasi yang lebih
lanjut dari infeksi tersebut seperti
Gradenigo’s syndrome
6. Apakah hasil test yang positif
memerlukan tindakan lanjutan
berupa tindakan intervensi, atau
pemeriksaan
lanjutan?
Jawaban : Ya
Setelah diketahui seorang
menderita Gradenigo’s syndrome ,
upaya pengobatan dan habilitasi
pendengaran harus dilakukan sedini
mungkin untuk mencegah kecatatan
dan complikasi yang lebih lanjut

17.  Kesimpulan: Berdasarkan hasil kritisi jurnal, didapatkan 4 jawaban “Iya”, 2
jawaban “Tidak” dari total 6 pertanyaan, sehingga dapat disimpulkan bahwa
jurnal dengan judul “Gradenigo’s Syndrome a Rare Complication of Acute Otitis
Media: Case Report and Literature Review” ini layak dibaca dan layak untuk
diadaptasikan sebagai penelitian lanjutan di RSUDZA.
DISCUSSION

18. Book report
My favourite
character
My favourite
part
It’s the smallest one in the Solar
System—it’s only a bit larger
than the Moon
It’s the second planet from the
Sun. It’s terribly hot, even
hotter than Mercury

19. You can describe the topic
of the section here
My book
01

20. A picture is worth a thousand words

21. Characters analysis
Characters
Venus is the second planet
from the Sun
Your opinion
Saturn is a gas giant and has
several rings
Plot
Earth is the third planet from
the Sun and the only one that
harbors life in the Solar System.
This is where we all live on

22. My favorite
phrase

23. Favorite character
It’s the closest planet to the Sun and
the smallest in the Solar System
The best part
Despite being red, Mars is actually a
cold place. It’s full of iron oxide dust
My favorite ones
The best place
Venus has a beautiful name and is the
second planet from the Sun
Favorite phrase
This planet's name has nothing to do
with the liquid metal

24. books read in a year
58

25. 5874
Is Jupiter's rotation period
254
Earths is the Sun’s mass
41
Is the distance between Earth and the Moon

26. Recommendations
It’s the farthest planet
from the Sun
Book 4
Book 3
It’s composed of
hydrogen and helium
Book 1
It’s the closest planet
to the Sun
Book 2
Venus is the second
planet from the Sun
Book 5
Mars is actually a very
cold place
Book 6
Jupiter is the biggest
planet of them all

27. Book card
Quick summary
Title:
Author:
Rating:
It’s the closest planet to the Sun
It’s the biggest planet in the Solar System
Venus is the second planet from the Sun
Best part
Jupiter is the biggest planet in
the Solar System
It’s a gas giant and has several rings.
It's composed of hydrogen and
helium

28. It’s the closest planet to the Sun and the smallest one in the Solar System—it’s only a
bit larger than the Moon. Venus has a beautiful name and is the second planet from
the Sun. It’s terribly hot, even hotter than Mercury, and its atmosphere is extremely
poisonous. It’s the second-brightest natural object in the night sky after the Moon
Book report 1
Title:
Author:
Description:
It’s the closest planet to the Sun
Venus is the second planet from the Sun

29. Readers of my book
Book 1
It’s the closest planet to the Sun
Book 2
Book 3
It’s actually a very cold place
Follow the link in the graph to modify its data and then paste the new one here. For more info, click here
It’s the second planet from the Sun
40% 35%
25%

30. Name Story Dialogue Rhythm Total pt
Name of the
book
6 points
Name of the
book
5 points
Name of the
book
7 points
Book ranking

31. Points of sale
Point 1
Point 4
It’s the biggest planet
The second planet from the Sun
Point 3
Earth is where we all live on
Point 2
It’s actually a very cold place

32. My two favorite authors
1. Mercury is the closest planet to the Sun and the smallest one in the Solar
System—it’s only a bit larger than the Moon
2. Venus has a beautiful name and is the second planet from the Sun

33. My book infographic
Venus
Venus is the second
planet from the Sun
Jupiter
Mars
Despite being red, Mars is
a cold place
It’s the biggest planet in
the Solar System
Saturn
Saturn is a gas giant and
has several rings

34. Book timeline
01
Venus
Venus is the second
planet from the Sun
03
Mars
Despite being red, Mars is
a cold place
Jupiter
It’s the biggest planet in
the Solar System
02

35. Book timeline
05
Mercury
It’s the closest planet to
the Sun
04
Saturn
Saturn is a gas giant and
has several rings
Neptune
It’s the farthest planet
from the Sun
06

36. ● Venus has a beautiful name
and is the second planet
from the Sun
● Mercury is the closest planet
to the Sun and the smallest
one in the Solar System
Write four sentences about the book
I like it I don't like it
● It’s the closest planet to the
Sun and the smallest in the
Solar System
● Despite being red, Mars is
actually a cold place. It’s full
of iron oxide dust

37. Photographs of my books
Mercury is the closest planet to
the Sun and the smallest one in
the Solar System—it’s only a bit
larger than the Moon

38. This is a graph
Follow the link in the graph to modify its data and then paste the new one here. For more info, click here
Mercury
It’s the smallest planet of them all
Mars
It’s actually a very cold place
Venus
It’s the second planet from the Sun
20 10
30
40
8
21
6
8
10

39. Book percentages
15% 50% 65%
Venus
The second planet
from the Sun
Mercury
It’s the closest
planet to the Sun
Mars
Mars is actually a
very cold place

40. Statistics per year
Books to read
Books read in 2019
60%
Genres
Novels read yearly
80%
Science books read yearly
60%
History books read yearly
40%
Books read in 2020
40%
Books read in 2021
80%

41. Book report
Write about the book
Title:
Write the title
here
Mercury is the closest planet to the Sun and the smallest
one in the Solar System—it’s only a bit larger than the
Moon. Venus has a beautiful name and is the second
planet from the Sun. It’s terribly hot, even hotter than
Mercury, and its atmosphere is extremely poisonous. It’s
the second-brightest natural object in the night sky

42. My ranking
Mercury
It’s the closest planet
to the Sun and the
smallest of them all
Venus
Venus has a beautiful
name and is the second
planet from the Sun
Mars
Mars is actually a cold
place. It’s full of iron
oxide dust

43. Book lesson
Learning about the book Title:
Write the title
here
Author:
Write the title
here
Despite being red, Mars is actually a cold place. It's full of
iron oxide dust, which gives the planet its reddish cast.
Earth is the third planet from the Sun and the only one
that harbors life in the Solar System. This is where we all
live on.
Mercury is the closest planet to the Sun and the smallest
one in the Solar System

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