INTRODUCTION: In 1904, Giuseppe Gradenigo published his case series on the triad 
of ipsilateral abducens nerve palsy, facial pain in the trigeminal nerve 
distribution, and suppurative otitis media, which would subsequently be referred 
to as Gradenigo syndrome.
CASE REPORT: Our patient was a 36-year-old female, 23 weeks pregnant, with a 
6-day history of right-sided otalgia and hearing loss and a 4-day history of 
purulent otorrhea, who presented with severe, holocephalic headache, meningeal 
signs, fever, photophobia, and mental status decline. Lumbar puncture yielded a 
white blood cell count of 1,559 cells/mm(3) with 95% polymorphonuclear 
leukocytes, a red blood cell count of 111 cells/mm(3), a protein level of 61 
mg/dl, and a glucose level of <40 mg/dl. Cerebrospinal fluid Gram stain showed 
Gram-positive diplococci, which were subsequently identified as Streptococcus 
pneumoniae and treated with ceftriaxone. On the second hospital day, she 
developed horizontal diplopia due to right abducens nerve palsy and right 
mydriasis. Both symptoms resolved on the third hospital day. Erosion of temporal 
bone and opacification of mastoid air cells was shown on CT scan. A CT venogram 
showed an irregularity of the left transverse and superior sagittal sinuses. She 
was treated with enoxaparin for possible sinus thrombosis.
DISCUSSION: This case demonstrates rare but serious sequelae of otitis media and 
Gradenigo syndrome. Holocephalic headache from meningitis masked trigeminal 
pain. Involvement of the ipsilateral petrous apex and surrounding structures on 
imaging and clinical improvement with antibiotic treatment supports Gradenigo 
syndrome over intracranial hypertension due to venous sinus thrombosis as the 
cause of the abducens nerve palsy.