A 51-year-old male presented to the outpatient department (OPD) of a tertiary care hospital with increasing purulent discharge from the left ear since 30 days and double vision since last 7 days. The discharge was yellowish and foul smelled. This was associated with left sided headache, severe in intensity which was maximal in the left frontotemporal region and deep retro-orbital region. Lately, he developed double vision, maximal in horizontal gaze when looking towards the left side disappearing on closing either of his eyes. There was no history of head injury, fever, abnormal behavior and altered bowel and bladder habits. There was a significant past history of on and off discharge from his left ear since the age of 25 years; however he did not take any treatment for it.

Clinical examination revealed stable vitals. Neurological examination showed left lateral rectus palsy and diminished touch, pain and temperature sensation in the ophthalmic division of left fifth nerve with absent ipsilateral corneal reflex (Figure 1). ENT evaluation revealed tenderness over left mastoid and a congested and perforated left tympanic membrane (Figure 2).There was no neck stiffness and meningeal signs were absent. Rest of neurological and systemic examination was normal.

Figure 1: Left lateral rectus palsy.

Figure 2: Left tympanic membrane showing congestion (black arrow) and perforation (white arrow).

His hematological and biochemical parameters were normal. Non contrast CT head and temporal bone revealed left mastoiditis with apical petrositis (Figure 3). He was started on injection amoxicillinclavulanate. He showed good response to therapy with decreasing pain and no further ear discharge. ENT consult was sought and he has been planned for left mastoidectomy and petrous exploration. However the patient was lost to follow up and did not report back.

Figure 3: NCCT head showing left apical petrositis (red arrow) and a normal aerated right mastoid cavity (yellow arrow).

Gradenigo’s syndrome was described in 1904 by Giuseppe Gradenigo as a symptom complex of suppurative otitis media, pain in the distribution of the trigeminal nerve, and abducens nerve palsy [1]. Gradenigo’s syndrome is an uncommon but life-threatening complication of otitis media. Deep facial or retro-orbital pain occurs because of stretching of the meningeal covering of the trigeminal ganglia and abducens nerve palsy occurs because of the inflammatory reaction in the Dorell’s canal through which abducens nerve passes.

In addition to the triad symptoms of Gradenigo’s syndrome, petrous apicitis may have other manifestations like involvement of ipsilateral 7^th cranial nerve causing facial paralysis, deficits in the distribution of other cranial nerves like 8^th, 9^th and 10^th ,causing vertigo and sensorineural hearing loss [2]. Our patient did not have any involvement of facial nerve but there was sensory loss in ophthalmic division of fifth nerve. With improved health care only a minority of patients exhibits the full triad of Gradenigo’s syndrome [3].The basic pathophysiology lies in the involvement of petrous apex by an inflammatory reaction. Petrous apicitis is an extension of infection from the mastoid air cells into a pneumatized petrous apex [4]. Most of the Gradenigo’s syndrome cases are caused by pyogenic bacteria but nontuberculous mycobacteria (NTM) has also been implicated [5].However, no organism could be grown in this case. Majority of the patients are seen by ENT specialist as they have a history of otalgia or otorohea. This case has presented to general medicine outpatient department with diplopa and was found to have left abducens nerve palsy .Further evaluation revealed chronic suppurative otitis media and had apical petrositis on NCCT temporal bone. Gradenigo’s syndrome remains a clinical diagnosis, however imaging like MRI and CT can help in planning a surgical approach. It has traditionally been treated surgically, but with better imaging and improved antibiotic treatment, many cases can be managed non-surgically [6].

This case reinforces the fact that meticulous ENT examination should be done in patients presenting with cranial nerve palsies and a clinical diagnosis can be made without any investigations. With better imaging and antibiotics more and more number of cases can be treated conservatively rather than employing upfront surgical approach.