Rare Gradenigo Syndrome With Retropharyngeal Abscess Resolved Rapidly in a 10-Year-Old

When a 10-year-old girl arrived at the hospital unable to move her right eye outward, struggling to swallow solid food, and complaining of pain behind her right eye, nothing about her ears seemed alarming enough to explain it. She had no fever. Her ear pain, which had begun ten days earlier, had already been partially treated with oral antibiotics. Yet within days, imaging and surgery would reveal one of the rarest and most dangerous complications of a childhood ear infection: Gradenigo syndrome accompanied by a retropharyngeal abscess, an infection collection deep in the neck that had climbed from the skull base toward her throat. The case, published in the Egyptian Pediatric Association Gazette by Dayanand Arumugam, Sebina Francis, and Vishnu Vardhini Devi Vijayasekar, documents how a condition once thought to have been largely tamed by antibiotics can still emerge in an incomplete, misleading form, and how rapid surgical and medical intervention reversed what could have become a lasting neurological injury.

Gradenigo syndrome is a rare but serious intracranial complication of otitis media, the common middle-ear infection that most children experience at least once. The syndrome arises when infection spreads contiguously from the middle ear or mastoid air cells to the petrous apex, the dense, wedge-shaped tip of the temporal bone that sits deep at the skull base. Inflammation of this region, called petrous apicitis, irritates adjacent cranial nerves and produces the classical triad first described by Giuseppe Gradenigo in 1907: persistent purulent ear discharge, deep retro-orbital pain caused by involvement of the trigeminal nerve, and paralysis of the abducens nerve, the sixth cranial nerve that controls the lateral rectus muscle of the eye. The pathological basis of the condition, petrositis, was subsequently detailed by Baldenweck in 1908. In the antibiotic era, the incidence of the syndrome has declined significantly, particularly among children, and the cases that do occur more often present atypically or incompletely, which makes diagnosis genuinely difficult.

The anatomy explains why the eye is so often affected. The abducens nerve takes a long intracranial course over the petrous apex, and it passes through the Dorello canal, a narrow osteofibrous channel at the skull base bounded above by the petroclinoid ligament, also known as Gruber’s ligament, and below by the petrous apex itself. When infection and inflammation occupy this confined space, the nerve is compressed or irritated, and the eye can no longer be abducted, producing double vision, or binocular diplopia, whenever both eyes are open. The trigeminal nerve, whose sensory ganglion sits in Meckel’s cave nearby, divides into ophthalmic, maxillary, and mandibular branches, and inflammation of these fibers can generate deep, unilateral facial and retro-orbital pain. In the reported child, the abducens palsy was classical: on examination she could not abduct her right eye at all, she held her head tilted to the right, and all other cranial nerves were intact.

What made this case unusual was what was missing. The girl had no persistent otorrhea, the discharge of pus from the ear that gives the syndrome its name. Her ear pain had been partially treated with oral antibiotics before referral, and three months earlier she had experienced an episode of right ear pain with muco-purulent discharge and fever that was treated conservatively with antibiotics and ear drops at a local hospital. She had then remained asymptomatic for nearly two months before the current complaints began. On presentation she was dull and lethargic but afebrile with stable vital signs, a detail the authors attribute to the prior partial antibiotic therapy masking systemic signs of infection. Ear examination showed only a dull right tympanic membrane with air-fluid levels, findings of serous otitis media that were strikingly disproportionate to the deep infection imaging would soon uncover. A 2 by 1 centimeter non-tender right jugulodigastric lymph node was the only neck finding.

Contrast-enhanced magnetic resonance imaging of the brain, performed before referral, told the real story. It demonstrated right otomastoiditis with skull-base osteomyelitis and erosions of the petrous apex, along with a 3.1 by 2.2 by 1.4 centimeter collection in the right retropharyngeal space that showed diffusion restriction and peripheral enhancement, the imaging signature of an abscess. The collection extended inferiorly to the nasopharynx and superiorly eroded the petrous apex. Bone marrow signal changes were present in the clivus and the right occipital condyle, with smooth pachymeningeal thickening and enhancement along the clivus, and enhancement was seen along the right seventh and eighth nerve complex. Nasal endoscopy revealed a right-sided nasopharyngeal bulge continuous with a corresponding bulge over the right posterior pharyngeal wall, which explained the girl’s dysphagia, worse for solids than liquids, as mechanical obstruction from the abscess. Based on the clinical and radiological picture, the team diagnosed right-sided Gradenigo syndrome secondary to acute otitis media, complicated by a retropharyngeal abscess.

Retropharyngeal abscess is an uncommon but serious complication of Gradenigo syndrome and represents an advanced stage of disease with potential risks of airway compromise, septic dissemination, and intracranial extension. Although such abscesses can develop through contiguous inferior spread of infection, in pediatric patients they more commonly arise from suppurative infection of the retropharyngeal lymph nodes, which receive lymphatic drainage from the nasopharynx, adenoids, posterior paranasal sinuses, and the middle ear. The authors note that a recently reported similar pediatric case by Guennouni and colleagues stressed that early surgical drainage combined with prolonged antibiotic therapy was crucial in preventing life-threatening complications, and they describe their own patient’s course as closely paralleling that experience. Connor and colleagues have also described petrous apicitis in which imaging showed petrous apex enhancement confluent with meningeal enhancement, findings similar to those observed in this child.

Management proceeded on the day of admission. After neurological consultation, the patient was started on broad-spectrum intravenous antibiotics. Laboratory investigations revealed microcytic hypochromic anemia with leukocytosis, neutrophilia, thrombocytosis, and an elevated erythrocyte sedimentation rate, and neurology and ophthalmology opinions were obtained. She then underwent incision and drainage of the right retropharyngeal abscess under general anesthesia, with approximately 10 milliliters of pus aspirated and drained transorally. Because persistent right serous otitis media with conductive hearing loss remained, she underwent right myringotomy with grommet insertion under intravenous sedation, in which thick mucoid effusion was suctioned from the middle ear and a ventilation tube was placed successfully. Pus culture showed no growth and GeneXpert testing was negative, meaning no pathogen was ever identified, a limitation the authors acknowledge explicitly.

The most striking result came almost immediately. Complete improvement in the right lateral rectus palsy was noted by postoperative day one, and ophthalmology review confirmed resolving abducens nerve palsy secondary to petrositis. The antibiotic regimen was prolonged: intravenous Cefoperazone-Sulbactam at 1.5 grams twice daily for 15 days, along with intravenous Metronidazole at 250 milligrams three times daily for 5 days, followed by oral Ciprofloxacin at 500 milligrams twice daily as advised by the neurology and pediatrics teams. Dosing followed standard pediatric weight-based guidelines, with higher-end dosing employed because of the skull-base osteomyelitis and deep neck space infection. The child’s diplopia, neck stiffness, and dysphagia resolved, her neurological examination was normal at discharge, and she went home on a six-week course of oral ciprofloxacin, tolerating the treatment without adverse events.

Follow-up reinforced the completeness of the recovery. At subsequent ENT examination the grommet was well positioned, with no residual nasopharyngeal or posterior pharyngeal wall bulge. Follow-up imaging performed four weeks later demonstrated reduction in skull-base inflammation with no evidence of any retropharyngeal collection, and the child remained asymptomatic with full neurological recovery. The authors emphasize that the case illustrates an atypical presentation in which neurological deficits dominated while classical ear findings, including persistent otorrhea, were absent, and that otoscopic findings deceptively mild in appearance may mask deep infection, making early radiological evaluation and vigilant clinical monitoring crucial. They also situate the case in a broader literature: Schmit and colleagues found the classic triad in only 22 percent of pediatric Gradenigo syndrome cases, with incomplete syndrome present in 74 percent of 48 patients, underscoring the need for early imaging even in atypical presentations. Kim and colleagues in 2024 reported a child with petrous apicitis and skull-base involvement despite minimal ear symptoms, and Villa and colleagues emphasized that acute-onset abducens nerve palsy in a child with a history of otitis media should raise suspicion for the syndrome even without overt otologic findings.

The authors are careful about the limits of what a single patient can show. They acknowledge that the report is constrained by its single-patient design and by negative culture findings, with no identifiable pathogen, so the microbiology of the infection remains unknown. Management strategies for Gradenigo syndrome vary with disease severity: selected early cases may respond to intravenous antibiotics alone, while complicated cases with abscess formation or neurological deficits require surgical intervention, as Vitale and colleagues and Jacobsen and colleagues have discussed, the latter highlighting prolonged antibiotic therapy particularly in cases associated with mastoiditis and anaerobic organisms. Acute otitis media itself remains extremely common, with up to 85 percent of children experiencing at least one episode during childhood, which is precisely why the authors argue that this rare outcome deserves attention from otolaryngologists, pediatricians, and neurologists alike. Their conclusion is practical rather than dramatic: in a child with cranial nerve palsy and any history of ear infection, neurological signs can be the earliest indication of deep-seated infection, and timely surgical drainage, middle ear ventilation, and targeted antibiotic therapy can still produce a rapid and complete recovery, preventing persistent neurological deficits before they take hold.

Subject of Research: A pediatric case report of Gradenigo syndrome with skull-base osteomyelitis and retropharyngeal abscess following acute otitis media

Article Title: Gradenigo syndrome with retropharyngeal abscess in a pediatric patient: a rare case report

Article References: Arumugam, D., Francis, S., & Vijayasekar, V. V. D. (2026). Gradenigo syndrome with retropharyngeal abscess in a pediatric patient: a rare case report. Egyptian Pediatric Association Gazette, 74(1), Article 122. https://doi.org/10.1186/s43054-026-00625-1

Image Credits: AI Generated

DOI: 10.1186/s43054-026-00625-1

Keywords: Gradenigo syndrome, retropharyngeal abscess, otitis media, petrous apicitis, skull-base osteomyelitis, abducens nerve palsy, diplopia, myringotomy, pediatric otolaryngology, case report, antibiotic therapy, cranial nerve palsy