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A 7-year-old previously well boy presented to the emergency department (ED) with diplopia and pain in his right eye for 2 days. The previous week, while on holiday abroad, he developed right ear pain and vomiting. He was seen by the local physician, diagnosed with right otitis media and was treated with eardrops. On returning to the UK, his general practitioner started him on oral amoxicillin, but his parents brought him to the ED due to worsening symptoms. There was no history of trauma, headache, vomiting or fever. He was fully immunised, was not on any regular medications and had no known allergies.
On examination, he was distressed due to photophobia in his right eye and diplopia. There was crusted discharge in his right ear canal with a perforated tympanic membrane. Cranial nerve examination revealed a loss of abduction of the right eye, but the rest of the neurological and systemic examination was normal.
Twitter Follow Mark Lyttle at @mdlyttle
Contributors SG and MDL conceived the idea. SG provided the initial draft of the manuscript and all authors contributed in arriving at the final version. ML provided expertise in the selection of the image.
Competing interests None declared.
Patient consent Parental/guardian consent obtained.
Provenance and peer review Not commissioned; externally peer reviewed.