A 7-year-old girl with long-standing left ear discharge develops pain deep behind the left eye and double vision worse on looking towards the left. Examination shows left lateral rectus palsy. The most likely diagnosis is:

• A Cavernous sinus thrombosis
• B Lateral sinus thrombophlebitis
• C Tolosa-Hunt syndrome
• D Apical petrositis (Gradenigo's syndrome) ✓

Explanation

Gradenigo's syndrome is the classical triad of persistent otorrhoea, retro-orbital (trigeminal V1 distribution) pain, and ipsilateral abducens palsy causing diplopia. It results from extension of middle ear infection to the petrous apex where the sixth nerve crosses Dorello's canal near the trigeminal ganglion. Cavernous sinus thrombosis causes ophthalmoplegia with proptosis and chemosis, not isolated sixth nerve palsy with ear discharge. Lateral sinus thrombosis produces picket-fence fever and papilloedema instead.

Reference: Dhingra's Diseases of Ear, Nose and Throat, 8th ed.

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Written and medically reviewed by the StethoPrep medical team.