Case

A 77-year-old man had a 1-day history of acute dysphagia to both solid and liquid, requiring nasogastric feeding. Thirty minutes after the dysphagia started he developed pain on the left ear radiating to the left side of his scalp. There was no dysarthria, odynophagia or dysgeusia. In 2008, he had developed a left medullary stroke with no residual deficit and had stable ischaemic heart disease. On examination, he had mild dysphonia and decreased left palatal elevation. There was no fatigable ptosis, nystagmus or Horner’s syndrome. His left ear was red and tender (figure 1); the left tympanic membrane was erythematous, with vesicles on it. The left side of the soft palate showed extensive ecchymosis and an ulcer (figure 2). The posterior third of the tongue was normal, but bedside nasoscope identified vesicles on the left side of the throat. His vocal cords were mobile. He had no fever, meningism or neck masses. Limb tone, reflexes, strength, sensation and …