Little Tommy's Tilted Cracked Pot

Tommy, an 8-year-old boy, began having recurrent episodes of morning vomiting and pain in the back of his neck. After 6 months, the episodes began to occur throughout the day, and he was unable to play or attend school. At about the same time, his mother noticed that he walked unsteadily with his head tilted to the right. Previously well, he had no history of birth injury or unusual childhood diseases, and his earlier growth and development had been normal.

On examination, percussion of the head produced a "cracked-pot" sound, the head was tilted to the right, and the neck was slightly stiff. There was bilateral papilledema; but the visual fields were normal, the pupils were equal, and the light reflexes were normal. There was coarse nystagmus on looking to the left and quick fine nystagmus on looking to the right, otherwise the eye movements were normal. The remainder of the cranial nerves were intact. The limbs were hypotonic, especially on the left, and there was bilateral heel-to-shin and finger-to-nose ataxia and intention tremor, also more marked on the left. His gait was wide-based and unsteady with a tendency to reel toward the left. Sensation and deep tendon reflexes were normal. The plantar reflexes were flexor.

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