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

Abstract Background Gradenigo syndrome is a rare complication of otitis media characterized by the classical triad of persistent otorrhea, retro-orbital pain, and abducens nerve palsy, resulting from petrous apicitis. With the advent of antibiotics, its incidence has significantly declined, especially in the pediatric population. Case presentation We report a rare and unusual case of a 10-year-old female child who presented with a 10 day history of right ear pain, neck stiffness, dysphagia, binocular diplopia, and retro-orbital pain following a history of treated acute otitis media. Imaging revealed right otomastoiditis with skull-base osteomyelitis and erosion of petrous apex, associated with retropharyngeal collection extending from the petrous apex to the nasopharynx, leading to the diagnosis of Gradenigo syndrome secondary to acute otitis media, associated with a retropharyngeal abscess. Immediate surgical drainage of the retropharyngeal abscess, followed by myringotomy with grommet insertion resulted in complete resolution of right lateral rectus palsy by postoperative day one, underscoring the importance of early intervention in preventing persistent neurological deficits. The patient also received prolonged intravenous followed by oral antibiotics, leading to complete neurological recovery. Conclusions This case illustrates an atypical presentation of Gradenigo syndrome, where neurological deficits dominated and classical ear findings, including persistent otorrhea, were absent. The occurrence of a retropharyngeal abscess secondary to skull-base osteomyelitis highlights a serious and uncommon complication in pediatric otitis media. Subtle otoscopic findings, disproportionate to the neurological deficits, may mask deep infection, making early radiological evaluation and vigilant clinical monitoring crucial. Timely surgical intervention combined with middle ear ventilation and appropriate antibiotics led to complete resolution of cranial nerve deficits. This report underscores the value of coordinated care across specialties and offers practical lessons for managing complex, high-risk pediatric ear infections.