Dear Sir,Nair et al.[1] In Sankara Nethralaya Abducens Nerve Palsy study: Report 1, have highlighted the importance of ruling out neurological signs prior to diagnosing isolated sixth nerve palsy. We appreciate the authors’ effort and research work. We would like to highlight a few points regarding sixth nerve palsy associated with ear and pharynx infection. Three of their patients had upper respiratory tract infection. Middle ear infection may cause isolated sixth nerve palsy without petrositis and raised intracranial tension.[2] Incidence of chronic suppurative otitis media (CSOM) disease is higher in developing countries especially among low socioeconomic society because of malnutrition, overcrowding, poor hygiene, inadequate health care, and recurrent upper respiratory tract infection.[3] The brainstem[4] contains vital nodes of all functional systems in the central nervous system, including the visual, auditory, gustatory, vestibular, somatic, and visceral senses, and the somatomotor as well as the autonomic nervous system. We observed an elderly, diabetic, male patient who had maxillary sinusitis, mastoiditis, and brain stem Virchow-Robin space presenting clinically as sixth nerve palsy of short duration. We advised (and explained) emergency otolaryngologist consultation since Gradenigo's syndrome is a life threatening but treatable condition. To conclude, the timing of the neuroimaging study, if sixth nerve palsy develops in a patient undergoing treatment for upper respiratory tract infection and/or CSOM is open for discussion. Varicella vasculopathy should be ruled out in idiopathic isolated sixth nerve palsy.[5]