Otitis, headache and nerve palsy

Abstract

Case 1:A 9-y-old boy was admitted with a 1-wk history of headaches (in the left frontal area, vertex and neck), pain in the left ear, diplopia, feeling of annoyance by noise in the left ear, malaise, fatigue, loss of appetite, and paleness for 3 d. The patient had been initially treated by oral antibiotic (amoxicillin at a dose of 40 mg/kg/d) for pharengitis before admission. Previous medical history was unremarkable. There was no history of ear infections.On physical and neurological examinations, the patient was pale and weak. He kept his head towards the left for normal vision. In a neutral head position, the left eye was medially deviated and had lateral gaze paralysis not exceeding the midline (Figure 1). The left tympanic membrane was congested. There were no signs of meningial irritation or mastoid tenderness, and the rest of the physical and neurological examinations were unremarkable. The laboratory examination findings were as follows: white blood cells (WBC) 12 700/mm 3 , haemoglobin 12.7 g/dl, and platelet count 625 000/mm 3 . There were no pathological findings on the peripheral blood smear. Blood chemistry was normal. C-reactive protein (CRP) was 87 mg/l, and erythrocyte sedimentation rate (ESR) was 121 mm/h. Cerebrospinal fluid (CSF) findings were normal. Culture results of blood, urine, pus and CSF were negative. Serology of human immunodeficiency virus (HIV), herpes simplex virus, cytomegalovirus, rubella, measles, Epstein-Barr virus and parvovirus B19 were also negative. Figure 2.Figure 1.