Petrous apicitis complicated by meningitis with intracranial air presenting as incomplete Gradenigo syndrome

Gradenigo syndrome is a rare complication of otitis media with extension of inflammation into the petrous apex of the temporal bone, that is, petrous apicitis. The classical triad of Gradenigo syndrome includes suppurative otitis media, ipsilateral abducens nerve palsy, and facial pain in the distribution of the trigeminal nerve. We present a unique case of incomplete Gradenigo syndrome complicated by meningitis with intracranial air. A 42-year-old female patient presented with left-sided suppurative otitis media with severe ipsilateral otalgia, deep facial pain, and generalized headache. Imaging revealed left otomastoiditis, petrous apicitis and a small amount of intracranial air in the area of Meckel’s cave. Cerebrospinal fluid analysis confirmed pneumococcal meningitis. Early initiation of treatment with high-dose intravenous antibiotics resulted in complete recovery. This case highlights that petrous apicitis can be associated with intracranial complications, even in the absence of abducens nerve palsy.