Torticollis in a child with otalgia

A 2 year old girl attended the emergency department with a slowly progressive, 10 day history of right sided otalgia and reduced neck movement. Worsening fevers, irritability, and poor oral intake in the previous 24 hours prompted presentation to hospital. Medical and birth histories were unremarkable, and she was up to date with immunisations.

On examination, the child was conscious, aware of her surroundings, and crying inconsolably. She had torticollis, with the head flexed and turned to the left. Any active or passive attempts to move it towards the midline induced severe pain; instead, the patient was rotating her chest to look around the room. She was feverish with temperatures as high as 40°C, dehydrated, and lethargic. Her ear canals were occluded with cerumen. The oral cavity was erythematous with mild trismus and no visible mass.

Neck palpation was normal with no lymphadenopathy or signs of abscess. Her voice was normal. She did not have photophobia or rashes. There were no signs of raised intracranial pressure such as vomiting, visual changes or deficit, and abnormal systemic or focal …