Background: Acute otitis media is one of the most common infections in children, but complications involving the facial nerve are rare, occurring in less than 1% of cases. Facial nerve palsy can result from inflammation, edema, or anatomical variations such as dehiscence in the facial canal, allowing for direct extension of infection.This case highlights a rare but important complication that clinicians should be aware of when assessing children with otitis media.Case Presentation: A previously healthy 1 year and 6 months old girl presented with a 5 day history of fever, pulling right ear, and poor oral intake. On the day of presentation, her parents noticed right-sided facial drooping and difficulty closing her right eye. On examination, the child was febrile (38.3°C). Otoscopy revealed a bulging, erythematous right tympanic membrane with loss of landmarks. Neurological examination showed a right lower motor neuron facial nerve palsy. The remainder of the neurological examination was normal, with no signs of mastoid tenderness, meningism, or other cranial nerve involvement.Investigations- Full blood count: within normal limits- C-Reactive protein: 46 mg/L- Ear swab: no growth- Blood cultures: no growth- Computed Tomography Brain: opacification of both middle ear and mastoid regions, no bony destruction, superficial/intracranial fluid collections to suggest mastoiditis.- Ultrasound abdomen: splenomegaly, otherwise normal- Nasopharyngeal aspirate: Adenovirus, Coronavirus HKU1, Rhinovirus- Pertussis swab: negativeTreatment- Intravenous cefotaxime for 16 days- Oral Prednisolone for 6 days- Beclomethasone ear drops: 3 drops. three times a day, for 2 weeks- Right grommet insertion and left ear examination, along with myringotomy- Lubricating eye drops and eye patching to protect the cornea- Multidisciplinary input from Otorhinolaryngology, Neurology, and Infectious Diseases teamsOutcome and Follow-Up: She was inpatient for 16 days and improved clinically during her stay. At a 2-week follow-up, the child had near-complete recovery of facial nerve function, with no residual weakness or complications. She had audiometry and MRI (Magnetic resonance imaging) brain as outpatients, which were both reported as normal.Discussion: Facial nerve palsy as a complication of acute otitis media is rare in the antibiotic era but remains clinically significant. The facial nerve passes through the temporal bone and is vulnerable to inflammatory changes due to its anatomical proximity to the middle ear. Pathogenesis includes inflammation, compression from edema, or direct extension of infection through a dehiscent bony canal. Management is typically medical, with high-dose antibiotics and corticosteroids. Most children recover fully, but delayed diagnosis can lead to permanent deficits.This case underscores the importance of detailed neurological examination in children presenting with ear infections, especially when there are subtle signs of facial asymmetry.Learning Points- Facial nerve palsy is a rare but serious complication of acute otitis media in children.- Early recognition and prompt treatment with antibiotics and corticosteroids can result in full recovery.- Eye care is crucial in lower motor neuron facial palsy to prevent corneal complications.- Consider neuroimaging if there are red flag signs
