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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 5  |  Page : 1152-1153

Recurrent petrositis due to nasopharyngeal carcinoma in an adult patient: Gradenigo's syndrome


1 Department of Medical Oncology, Medical Faculty, Firat University, Elazig, Turkey
2 Department of Neurology, Medeniyet University, Medical Faculty, Istanbul, Turkey

Date of Web Publication7-Sep-2018

Correspondence Address:
Asude Aksoy
Department of Medical Oncology, Medical Faculty, Firat University, TR-23119, Elazig
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.189223

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 > Abstract 


The early diagnosis of very rare nasopharyngeal carcinoma (NPC) is so difficult, to surrounded by structures such as the orbital skull base. With the invasion of the disease, the symptoms are manifested in different ways so that it may be confusion and delay in diagnosis and treatment in this situation. Including otological symptoms (serous otitis media), Gradenigo's syndrome is a rare clinical condition. The majority of published cases involve children, and the most common etiology is otitis media. We report a case of a diabetic man who presented with repeating Gradenigo's syndrome symptoms due to NPC.

Keywords: Gradeningo's syndrome, mastoiditis, nasopharyngeal carcinoma


How to cite this article:
Aksoy A, Varoglu AO. Recurrent petrositis due to nasopharyngeal carcinoma in an adult patient: Gradenigo's syndrome. J Can Res Ther 2018;14:1152-3

How to cite this URL:
Aksoy A, Varoglu AO. Recurrent petrositis due to nasopharyngeal carcinoma in an adult patient: Gradenigo's syndrome. J Can Res Ther [serial online] 2018 [cited 2021 Oct 16];14:1152-3. Available from: https://www.cancerjournal.net/text.asp?2018/14/5/1152/189223




 > Introduction Top


Nasopharyngeal carcinoma (NPC) is different from other head and neck cancers in terms of anatomical localization. It has an insidious onset and nonspecific features in the early stage. The diagnosis and management of the disease may be a disturbance.[1] Gradenigo's syndrome is defined as a clinical triad of otitis media, severe retro-orbital pain in the trigeminal nerve distributions, and ipsilateral sixth cranial palsy. The most common etiology of this syndrome is an infection.[2] We reported a case that differs from these published reports: An NPC the etiology of Gradenigo's syndrome; the presence of recurrent symptoms of the syndrome persisted in a patient.


 > Case Report Top


A 52-year-old man was admitted to neurology clinic due to the left postauricular and retrobulbar pain and diplopia as well as numbness on the trigeminal nerve distributions, which had lasted for 3 weeks. The neurological examination revealed the presence of paresis of the left sixth cranial nerve and hypoesthesia on the trigeminal nerve distributions of the ophthalmic and maxillary branch. In addition, a bilateral cornea reflex was present. The brain magnetic resonance imaging (MRI) scan was normal, but a computed tomography investigation revealed petrous apicitis and mastoiditis in the left temporal bone. The patient was diagnosed with subacute otitis media and treated with medical antibiotherapy, after corticoid-therapy. Furthermore, mastoidectomy surgery was performed, and the patients' complaints were partially resolved. Two weeks later, he was admitted to the outpatient clinic again with the same complaints. A nasopharyngeal MRI [Figure 1] revealed large numbers of lymph nodes. After conducting multiple biopsies by flexible nasopharyncoscopic examination, the pathologic diagnosis was x [Figure 2]. Therefore, he was diagnosed as having Gradenigo's syndrome, resulting from NPC. The patient was immediately referred to the medical oncology department. The patient was evaluated as locally advanced stage NPC according to the American Joint Committee on Cancer 7.[3] Three cycles of platinum-taxane containing induction chemotherapy regimen was administered, and after concurrent chemoradiotherapy (including platinum chemotherapy) was applied.[1] The patient was observed without any medical treatment and complaint in follow-up.
Figure 1: Nasopharyngeal magnetic resonance imaging: (a) Unilateral enlargement of lymph node in nasopharyngeal zone. (b) Bilateral enlargement of lymph nodes in nasopharyngeal zone

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Figure 2: Tumoral lesion composed of solid sheets of squamous cells with pleomorphic vesicular nuclei, prominent nucleoli, and light eosinophilic cytoplasmic borders (H and E, ×100)

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 > Discussion Top


In 1904, Gradenigo described a triad of symptoms related to petrous apicitis, including acute suppurative otitis media, deep facial pain resulting from trigeminal involvement, and abducens nerve palsy.[2] It is well-known that petrous apicitis is extremely rare; additionally, this complication of otitis media is life-threatening. In the literature, petrous apicitis is generally seen in pediatric age groups.[4],[5] According to these reports, the treatment of petrous apicitis is still controversial. Some authors suggest that conservative antibiotic therapy is effective.[4],[6] However, others revealed that a combination of surgical intervention, high dose intravenous antibiotics, systemic corticoid-therapy, and hyperbaric oxygen therapy are successful.[7],[8]

In this case, intravenous antibiotics and corticosteroid therapy were applied, and a mastoidectomy was performed. Despite aggressive treatment, his complaints resumed after 2 weeks. After multiple flexible nasopharyncoscopic examinations, nasopharyngeal keratinizing squamous cell carcinoma was diagnosed. In the literature, there is a few report about Gradenigo's syndrome due to NPC.[6],[9] In these reports, only Tutuncuoglu et al. reported a child with Gradenigo's syndrome that resulted from NPC.[6] In published records, most adult patients with Gradenigo's syndrome recovered after conventional treatments. In the present case, despite aggressive treatment, symptoms of this syndrome repeated after a short period. In such cases, it should be kept in mind that may be a local invasion of any head and neck's carcinoma. Early diagnosis for NPC is very difficult, therefore, surrounded by structures such as the orbital skull base. The time between diagnosis and onset of the disease is usually long for NPC. This time is generally about 6–10 months. NPC are evolved mostly from Rosenmuller fossa and basis of nasopharyngeal wall. It may spread through neighborhood, and the most commonly posterolateral invasion to foramen lacerum, cavernous sinus.[1] The incidence of the involvement of the nerves within the cavernous sinus is 12–35%.[10] In conclusion, we may suggest that the presence of recurrent symptoms in adult cases may point to Gradenigo's syndrome, resulting from NPC. It is a rare clinical entity that must be kept in mind; there is need a multidisciplinary approach including neurologist, otolaryngologist, medical oncologists, and radiation oncologists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Phister DG, Spencer S, Adelstein D, Atkins D, Brizel DM, Burtness B, et al. Head and neck cancers: National Comprehensive Cancer Network (NCCN): Clinical Practice Guideles in Oncology. V. 1. 2016; MS.23-25. Available from: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf.  Back to cited text no. 1
    
2.
Sherman SC, Buchanan A. Gradenigo syndrome: A case report and review of a rare complication of otitis media. J Emerg Med 2004;27:253-6.  Back to cited text no. 2
    
3.
Compton CC, Byrıd RD, Garcia J, Kurtzman SH, Olawaiye A, Washington MK. AJCC Cancer Staging Manual and Handbook. 7th ed. New York: Springer; 2010. p. 94-8.  Back to cited text no. 3
    
4.
Rossor TE, Anderson YC, Steventon NB, Voss LM. Conservative management of Gradenigo's syndrome in a child. BMJ Case Rep 2011;2011. pii: Bcr0320113978.  Back to cited text no. 4
    
5.
Plodpai Y, Hirunpat S, Kiddee W. Gradenigo's syndrome secondary to chronic otitis media on a background of previous radical mastoidectomy: A case report. J Med Case Rep 2014;8:217.  Back to cited text no. 5
    
6.
Tutuncuoglu S, Uran N, Kavas I, Ozgur T. Gradenigo syndrome: A case report. Pediatr Radiol 1993;23:556.  Back to cited text no. 6
    
7.
Bloching M, Heider C, Amm S, Kösling S. Gradenigo syndrome – Still a threatening complication of otitis media. HNO 2005;53:884-8.  Back to cited text no. 7
    
8.
Al-Ammar AY. Recurrent temporal petrositis. J Laryngol Otol 2001;115:316-8.  Back to cited text no. 8
    
9.
Pomar Blanco P, Díaz Suárez I, Gil-Carcedo LM, Vallejo Valdezate LA. Carcinoma of the nasopharynx, radiotherapy, otitis, labyrinthitis, inflammation of the petrous bone, meningitis. An Otorrinolaringol Ibero Am 1999;26:169-79.  Back to cited text no. 9
    
10.
Turgut M, Ertürk O, Saygi S, Ozcan OE. Importance of cranial nerve involvement in nasopharyngeal carcinoma. A clinical study comprising 124 cases with special reference to clinical presentation and prognosis. Neurosurg Rev 1998;21:243-8.  Back to cited text no. 10
    


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