Pediatric Emergency Medicine

Gradenigo’s Syndrome and Otitis Media

Sean M. Fox, MD
Assistant Professor
Adult and Pediatric Emergency Medicine
Carolinas Medical Center, Charlotte, NC

We have discussed how exciting the management of otitis media can be.  I know continuing to overwhelm you with acute otitis media (AOM) information will not likely increase your viewership of the Web site. But more seriously, it is often the seemingly “simple” things that can trip us up.  So here is one aspect of AOM that should be considered.  Appropriate documentation will help demonstrate that you smartly consider it on the DDx:  Gradenigo’s Syndrome.

  • Gradenigo’s Syndrome
    • First described by Guisseppe Gradenigo in 1907.
      • Reported a syndrome of constant otorrhea, headache, and diplopia
      • Later this was attributed to inflammation of the petrous apex.
    • Was once a more common entity… but our exuberant use of antibiotics has greatly reduced its occurrence.
  • Characterized by the following
    • Suppurative Otitis Media
    • Ipsilateral Facial Pain in the Trigeminal Nerve Distribution
    • Ipsilateral Abducens (CN VI) palsy
  • Due to the following
    • Extension of the AOM infection to the temporal bone (petrous apex)
    • Inflammation due to the apical petrositis then involves the adjacent trigeminal ganglion and abducens nerve
    • This inflammation and infection may spread further leading to:
      • Meningitis
      • Intracranial Abscess
      • Prevertebral/parapharyngeal abscess
      • Involvement of CN IX, X, XI (Vernet’s Syndrome)
      • Involvement of the sympathetic plexus around the carotid sheath (Horner’s Syndrome)
  • Radiographic evidence
    • CT scan can evaluate for mastoid and petrous air cell opacification and possibly boney destruction and rule-out abscess formation (like you would do for mastoiditis).
    • MRI can help demonstrate inflammation in the temporal bone (petrous apicitis).


  • Even “simple” processes that we deal with every day can become complicated.
  • While you may never see mastoiditis, never mind Gradenigo’s Syndrome, it is good clinical practice to actively evaluate the cranial nerves and palpate the mastoid process with all of your patients who you diagnose with AOM. 
  • Documenting the lack of CN abnormalities, lack of mastoid tenderness, and lack of pinnae asymmetry is a good way to demonstrate that you are thinking about potential complications as well as dealing with the issue at hand. 
  • And by being diligent and thorough, even with the seemingly “simple,” you will be the one to catch that zebra as it gallops by from time to time.


1.Motamed M, Kalan A. Gradenigo’s Syndrome. Postgrad Med J. 2000; 76: 559-560.

2.Hardjasudarma M, Edwards RL, Ganley LP, Aarstad RF. Magnetic Resonance Imaging Features of Gradenigo’s Syndrome. American Journal of Otolaryngology. Vol 16(4); 1995: 247-250.

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