Neurology

A 15-year-old female with PCOS, obesity, asthma, and recurrent otitis media with bilateral tympanostomy tube placement reports three weeks of increasing sanguineous drainage, ear pain, fevers, and worsening left-sided headaches not improving with NSAIDs.  She localizes the pain behind the left eye and additionally reports loss of lateral vision in her left eye, as well as double vision when looking to the left. On exam, she has a thickened, inflamed appearing left tympanic membrane with sanguinopurulent drainage from the left tympanostomy tube. She additionally has tenderness and swelling to the left mastoid process. Examination of the eyes reveals normal, symmetric, and reactive pupils.  The patient has binocular horizontal diplopia on left lateral gaze and downgaze, which resolves with covering either eye.  She has decreased vision in the lateral visual fields of the left eye on confrontational field exam.