Gradenigo syndrome in a child: case report and literature review

Gradenigo syndrome is a rare but potentially serious complication of suppurative otitis media, characterized by the classic triad of suppurative otorrhea, abducens nerve (VI) paralysis, and pain in the trigeminal nerve (V) territory. Although the advent of antibiotic therapy has significantly reduced its incidence, this condition remains relevant, particularly in children, requiring early recognition and appropriate multidisciplinary management.

We report the case of a 13-year-old girl who presented with a painful swelling behind her right ear that had been developing for a year, accompanied by headaches, pain behind her right eye, and earache, along with a fever. Clinical examination revealed severe bulging of the right tympanic membrane, inflammatory retro auricular swelling, and decreased right ocular mobility in abduction with diplopia, suggestive of abducens nerve involvement. Imaging (CT scan of the temporal bone and brain) confirmed the diagnosis, showing a right mastoid subperiosteal abscess with complete opacification of the tympanic cavity, bone lysis of the external wall of the mastoid, and filling of the petrous apex. Treatment consisted of intravenous antibiotic therapy (third-generation cephalosporin (Ceftriaxone 50 mg/kg/day IV) and metronidazole (30 mg/kg/day IV)) for 15 days, short-term corticosteroid therapy, drainage of the collection, and drainage mastoidectomy due to persistent symptoms.

This case perfectly illustrates the contemporary evolution of Gradenigo syndrome, where incomplete forms predominate. The pathophysiology involves the spread of infection from the middle ear to the petrous apex. Current microbiological data identify Fusobacterium necrophorum as the most common pathogen, justifying the systematic use of an anti-anaerobic agent. Modern management combines prolonged antibiotic therapy with surgery. Our patient's progress, marked by the disappearance of retro-orbital pain on the 5th postoperative day and complete recovery of ocular mobility on the 10th day, is consistent with the usual recovery times (median of 11 days after surgery).

Gradenigo syndrome remains a serious complication of otitis media requiring early diagnosis and multidisciplinary management. The evolution of clinical presentations toward incomplete forms requires an adaptation of traditional diagnostic criteria. With appropriate management combining prolonged antibiotic therapy and surgery when necessary, the prognosis is generally favorable. This case highlights the importance of maintaining a high degree of clinical suspicion in the presence of any complicated otitis in children, particularly when associated neurological signs are present.