A 90-year-old man presented to the emergency department with multiple symptoms including double vision, reduced mobility, dysphagia, recent rapid weight loss, ear discharge and deafness. He had diabetes and other chronic medical problems, including otitis media with mastoiditis. This case highlights the difficulty of investigating weight loss in older people, who may not show the usual clinical features of infection, and of distinguishing between infection and malignancy when radiological findings are inconclusive. His eventual diagnosis was osteomyelitis of the skull base with cranial nerve involvement.