A 28-year-old woman presented with fever, double vision, and facial pain. Neurologic examination showed neck stiffness, pain
in the distribution of the right trigeminal nerve, and right abducens palsy (figure 1). Tympanic membranes were normal. MRI revealed sphenoid sinusitis, basilar pachymeningitis, and clivus osteomyelitis (figure 2). CSF analysis showed pleocytosis, increased protein contents, decreased glucose levels, and positive cultures for Staphylococcus aureus.
The triad of suppurative otitis media, pain in the distribution of the
trigeminal nerve, and abducens palsy is called Gradenigo
syndrome.1 While it most often affects children, it may occur in adults and may rarely present without otitis media.2 While bone compromise is usually confined to the petrous apex, it may extend to sphenoid sinuses, clivus, and basal meninges.
Figure 1
Photograph of the patient shows isolated right abducens palsy
Figure 2 Head MRI
Contrast-enhanced
T1-weighted MRI of the head shows mucosal thickening of sphenoid sinuses
(arrowheads), basilar and right
middle fossa pachymeningitis (small arrows), and
osteomyelitis of the clivus (large arrow). While the right abducens
nerve
is not well visualized, it could be inferred in
the axial sections (upper row) that it is entrapped throughout the
Dorello
channel and the cavernous sinus.
