Lauren Len Spiegel, MD1; Lily C. Pham, MD1; Pitchaiah Mandava, MD, PhD, MSEE1,2

1Baylor College of Medicine, 2Michael E. DeBakey Veterans Affairs Hospital

The Danger of Flying with Acute Otitis Media, Which May Result in Gradenigo's Syndrome

67-year-old right-handed male former warehouse worker with a past medical history of HTN, HLD, COPD, alcohol dependence, childhood epilepsy, and treated syphilis presented with sudden onset left-sided facial numbness and hearing loss. His symptoms began acutely during airplane descent with a “popping” sensation in his left ear. He endorsed rhinorrhea for two days prior to presentation.

History of Present Illness

On descent, ambient pressure increases, while middle ear pressure is relatively unchanged. In otitis media, the patient is unable to equalize this pressure through opening the eustachian tube.7

The patient was diagnosed with bullous myringitis with temporal bone inflammation involving CN V and CN VIII. Due to initial concern for vesicles on examination, acyclovir was administered briefly, but discontinued. Patient was discharged with Amoxicillin / Clavulanate. We describe a case of Gradenigo's syndrome triggered by descent from high altitude during air travel. Patient with otitis media may experience adverse side effects from air travel due to the increase in atmospheric pressure during flight descent.4,9

In decreasing frequency, cranial nerves V, VIII, VII, and VI are most commonly implicated in Gradenigo’s syndrome.2

1. Matis, G. K., de, A. S. D. O., Chrysou, O. I., Karanikas, M. A., & Birbilis, T. A. (2012). Giuseppe Gradenigo: Much more than a syndrome! Historical vignette. Surg Neurol Int, 3, 122. doi:10.4103/2152-7806.102343.

2. Stephens, D., et al. (1997). Giuseppe Gradenigo and his contributions to audiology. J Laryngol Otol 111(5): 418-423.

3. Sherman, S. C., & Buchanan, A. (2004). Gradenigo syndrome: a case report and review of a rare complication of otitis media. J Emerg Med, 27(3), 253-256.doi:10.1016/j.jemermed.2004.03.014.

4. Carvalho, A. M., & Poirier, V. (2009). So you think you can fly?: Determining if your emergency department patient is fit for air travel. Can Fam Physician, 55(10), 992-995.

5. Hawke, Michael (2012) Normal Left Tympanic Membrane.jpg. Wikimedia Commons, the free media repository. Viewed 26 March 2018, https://upload.wikimedia.org/wikipedia/commons/e/e2/Normal_Left_Tympanic_Membrane.jpg.

6. Welleschik, B (2006) Otitis media bullös.jpg. Wikimediat Commons, the free media repository. Viewed 25 March 2018, https://upload.wikimedia.org/wikipedia/commons/a/ae/Otitis_media_bullös.jpg.

7. Kanick, S. C., & Doyle, W. J. (2005). Barotrauma during air travel: predictions of a mathematical model. J Appl Physiol, 98(5), 1592-1602. doi:10.1152/japplphysiol.00974.2004.

8. Lynch, P. J. (2006). Skull, brainstem and inner ear area. Viewed 25 March 2018, https://upload.wikimedia.org/wikipedia/commons/3/3c/Skull_and_brainstem_inner_ear.svg.

9. Sade, J., Ar, A., & Fuchs, C. (2003). Barotrauma vis-a-vis the "chronic otitis media syndrome": two conditions with middle ear gas deficiency Is secretory otitis media a contraindication to air travel? Ann Otol Rhinol Laryngol, 112(3), 230-235. doi:10.1177/000348940311200307.

14.9

44.7

1134.2 28 0.79

139 101 924815.6

• Gradenigo’s syndrome includes a triad of ipsilateral tri-geminal neuralgia, ipsilateral paresis of abducens nerve, and infection of the ear involving the petrous apex of the temporal bone.1,2

• Gradenigo’s syndrome is rare, given the frequently

prompt antibiotic treatment for otitis media.3

• Patients with otitis media should consider not flying.4

In the right clinical context, patients presenting to the emergency department with acute unilateral cranial neuropathies and an otologic examination suspicious for infection, one should consider peripheral etiologies involving middle ear and middle cranial fossa of the skull base, in addition to central nervous system etiologies to explain the patient’s constellation of symptoms.

A

Adapted from ”Normal Left Tympanic Membrane," by Michael Hawke, 2012, retrieved from https://upload.wikimedia.org/wikipedia/commons/e/e2 Normal_Left_Tympanic_ Membrane.jpg5

B

Adapted from “Otitis medis bullös,” by B. Welleschik, 2006, retrieved from https://up-load.wikimedia.org/wikipedia/commons/a/ae/Otitis_media_ bullös.jpg.6

Figure 2. Otoscopic view of the left ear of a normal patienta and a patient with bullous myringitisb. Note the bullae in the inferior tympanic membrane.

Figure 1. Axial CT Head with contrast images demonstrating left external auditory canal wall thickening with lobular density obscuring the left tympanic membrane. Soft tissue density within the left lateral epitympanic recess, mesotympanum and hypotympanum.

Gen: Thin male in no acute distress with frequent cough.

HEENT: Tender pinna. Erythematous auditory canal with bulgingerythematous tympanic membrane with a bulba obstructing 80% of the tympanic membrane.

MS: A&Ox3.

CN: Left V1-V3 numbness, decreased L hearing.

Motor: Tone normal. Strength 5/5 throughout.

Sensory: Intact.

Reflexes: 2+ throughout. Absent Babinski.

Gait: Narrow-based with normal stride.Download

poster

Figure 3. Change in cabin pressure for 170-min flights departing from Pittsburgh, PA (PIT) and arriving at Miami, FL (MIA), PIT, and Denver, CO (DEN).

Adapted from “Barotrauma during air travel: predictions of a mathematical model,” by S. Kanick and W.J. Doyle, 2005.7

10500

10000

9500

9000

8000

8500

750020 40 16014012010060 800 180

End of Ascent Start of Descent

Time (min)

Destinations:

DENPITMIA

P C

ab

in (

mm

H2O

)

Adapted from “Skull, brainstem, and inner ear area,” by Patrick J. Lynch, 2006, retrieved from https://upload.wikime-dia.org/wikipedia/commons/3/3c/Skull_and_brainstem_inner_ear.svg.8

Figure 4. Anatomic representation of the cranial nerves exiting the middle cranial fossa.

V1V2V3

IIIIVVI

VIIVIII