Double Vision and Ear Discharge in a 14-Year-Old Girl

Olugbemiga Jegede, MD; Walid Abuhammour, MD


December 09, 2015

Physical Examination and Workup

Upon examination, the patient is a young white girl who is ill-appearing but in no obvious distress. Her vital signs include a temperature of 97.9°F (36.6°C), a regular heart rate of 86 beats/min, a respiratory rate of 16 breaths/min, and a blood pressure of 110/80 mm Hg. On examination of the head, swelling and tenderness are noted behind the left ear lobe, with purulent bloody discharge from the left ear.

The central nervous system (CNS) examination reveals an alert and well-oriented young girl with a Glasgow Coma Score of 15/15. She is unable to wrinkle the left side of her forehead, she cannot close her left eyelid, and the left nasolabial fold is flat and with deviation of the mouth to the right. The cardiovascular, respiratory, and abdominal examinations are all normal.

The initial laboratory analysis, which includes a complete blood cell count and basic metabolic panel, are normal. CT scanning of the brain confirms a left-sided mastoiditis, but no findings to suggest increased intracranial pressure are noted. An analysis of the cerebrospinal fluid (CSF) shows no significant white or red blood cells or abnormalities in the glucose and protein concentrations. A swab of the purulent discharge from the left ear, blood, and CSF samples are sent for culture.

Figure 1.

Figure 2.

She is admitted for suppurative otitis media, mastoiditis and seventh nerve palsy. Infectious disease, head and neck surgery, and neurology specialists are consulted. Her initial management includes intravenous fluid, pain medications, tympanostomy for drainage and culture, and intravenous meropenem pending the culture and sensitivity results.

On admission day 2, however, the patient develops severe left orbital pain, double vision, and the inability to abduct the left eye. The neurologist clinically confirms a sixth nerve palsy, and a request is made for MRI of the temporal bones as well as magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) to rule out venous sinus thrombosis.

The MRI report is obtained (see Figures 1 and 2).


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