Insights into Gradenigo syndrome: Case presentation and review

Abstract

Gradenigo syndrome (GS) is characterized by a triad of clinical features: abducens nerve palsy, retro-orbital pain, and otorrhea, arising as a complication of suppurative otitis media. Herein, we present a case of GS in a 15-year-old male patient, secondary to left otitis media. The patient exhibited fever, otorrhea, accompanied by diplopia, retrobulbar pain, and headache. Imaging studies demonstrated petrous bone destruction and inflammatory changes with opacification of petrous bone, mastoid cells and surrounding structures, confirming the diagnosis of GS. Treatment included intravenous antibiotics and anticoagulants, resulting in the resolution of symptoms and radiological improvement. GS, though rare, warrants prompt recognition and appropriate management to prevent severe complications. Diagnostic imaging plays a crucial role in evaluation, and treatment often involves prolonged antibiotic therapy and, in severe cases, surgical intervention. Understanding the clinical presentation and management strategies is essential for clinicians encountering this condition.

Keywords: Abducens nerve palsy; Gradenigo syndrome; Otitis media; Petrous apicitis; Retro-orbital pain.

Fig. 1

CT scan showing: (A) opacification of the petromastoid left air cells and the middle ear (white arrow). (B) Rim enhancing lesion around the petrous apex (red arrow). (C) Rim enhancing retropharyngeal lesion (yellow arrow).

Fig. 2

MRI of the brain: (A) Noncontrast coronal T2-weighted MRI demonstrating left mastoid opacification (white arrow). (B) FLAIR MRI shows hyperintensity suggestive of fluid within the petrous temporal bone (red arrow). (C) Post gadolinium contrast T1 axial shows ring-enhancing lesion at the petrous apex (red arrow). (D) The lesion with hyperintensity in axial diffusion-weighted image (DWI) (red arrow).

Fig. 3

MRI showing Extensive and heterogenous enhancement in surrounding structures (A) (white arrow) with retropharyngeal lesion with hyperintensity in FLAIR (B) and rim enhancement (C) (red arrow).

Fig. 4

(A) Axial brain CT scan centered on the left petrous bone showing significant improvement in the aeration of mastoid cells and the middle ear (white arrow). (B and C) Axial contrast-enhanced brain CT scan demonstrating the resolution of retropharyngeal lymphadenopathy and petrous abscess (red arrows).