Acute abducens nerve palsy and weight loss due to skull base osteomyelitis.

Clinical record A 90-year-old, previously fit Estonian man was admitted to hospital from the emergency department (ED) with multiple symptoms including acute diplopia, difficulty with walking, several falls over 2 weeks, decreased taste sensation, dysphagia with solids over several months, a 10 kg weight loss over 5 months, and a 6-week history of otalgia, aural fullness, otorrhea, and deafness. Four months earlier, the patient had presented to the ED with acute onset of left facial nerve palsy, dysphonia and dysphagia. The facial nerve palsy had resolved spontaneously after 2 weeks without specific treatment. The patient had several significant background medical problems: late-onset diabetes mellitus of 17 years’ duration; peripheral neuropathy; chronic atrial fibrillation; hypertension; and chronic left otitis media with effusion and mastoiditis, for which he had been treated with insertion of a tympanostomy tube 5 months before admission, and a short course of a topical corticosteroid and an oral antibiotic 1 month before admission. The dysphagia was investigated before admission with a barium meal, oesophageal manometry and gastroscopy, which showed severe oesophageal dysmotility and no obstructive lesion. The patient was an ex-smoker with a 55 pack-year smoking history, regular moderate alcohol intake, and occasional salted fish but no areca (or “betel”) nut consumption (which have been linked to nasal and oral cancers, respectively). There was no family history of cancer. His regular medications included metformin, gliclazide, amiodarone, lercanidipine, frusemide and amitriptyline. The main findings on examination included failure of abduction (but no medial deviation) of the left eye consistent with abducens nerve palsy, bilateral haemoserous ear discharge, cachexia, and unsteady gait. No other localising neurological signs were found. The patient remained afebrile throughout the admission. A bedside swallowing assessment by a speech pathologist demonstrated moderate pharyngeal dysphagia. Communication with the patient was conducted through writing. The results of blood tests were unremarkable: his creatinine level