- Email: [email protected]
Blunt trauma leading to facial nerve paralysis
The Journal
of Emergency
Medune,
Vol. 9, pp. 27-28,
BLUNT TRAUMA
Printed
1991
LEADING TO FACIAL Michael J. Williams,
Reprint
address:
Michael
INTRODUCTION Facial paralysis due to blunt injury to the facial nerve is rare. In a series of 268 patients with traumatic injuries to the facial nerve, evaluated between 1962 and 1983, May (1) described only 3 cases due to blunt trauma distal to the stylomastoid foramen. In 1986 he reported 375 cases of facial nerve disorders due to trauma, an incidence of 19% of all causes of facial nerve disorders in the series (Table l), with only 4 cases due to blunt trauma.
RECEIVED: ACCEFTED:
Press plc
NERVE PARALYSIS
Infirmary, Hull, England Medicine, Hull Royal
Infirmary.
Anlaby
Road.
DISCUSSION Facial nerve paralysis in children is well described; however, a search of the literature shows that extracranial blunt injury to the nerve distal to the stylomastoid foramen is uncommon (1). The majority of the cases involving external trauma leading to facial paralysis are associated with fractures of the temporal bone (2). Plain film skull x-ray studies usually offer little information; high resolution computed tomography (CT scan) can give an accurate localization of the fracture site (3). The timing of surgery to decompress or repair the nerve and the role of electrophysiological testing are controversial (4). Haiman (5). in a retrospective
CASE HISTORY
=
0 1991 Pergamon
thereafter his parents noticed that the child appeared to be making grimacing movements of his face. Later in the day they noticed he could not close his left eye normally. Examination the next morning revealed a lower motor neuron, complete facial palsy. Physical examination revealed no evidence of tenderness or bruising over the nerve, although the child said that it had been painful locally at the time of injury. There was no evidence of a basal skull fracture, Battle’s sign was absent, and the tympanic membrane looked normal. Plain film-ray examination showed no evidence of bony injury. Appropriate eye care was initiated. Follow up of the paralysis revealed complete resolution in three weeks without specific treatment.
c] Keywords - facial nerve; paralysis; blunt trauma
A 4-year-old boy gency Department to the left side of been accidentally
CopyrIght
MB, FRCS
Registrar in Accident and Emergency Medicine, Hull Royal J. Williams, MB, FRCS, Registrar in Accident and Emergency Hull, England, HU3 2JZ
0 Abstract - A case in a young child of blunt trauma to the facial nerve, distal to the stylomastoid foramen, is reported. Although the patient made an uneventful recovery, an understanding of the possible sites of iqjury of the facial nerve and further investigations available to aid diagnosis is important. This child was followed up in the Accident and Emergency Department, however, early referral of this rare condition to an otolaryngologist is advisable.
In the USA.
presented to the Accident and Emer(A&E) with a history of direct trauma his face 24 hours previously. He had kicked by an older sibling; shortly
Clinical Communications: Pediatrics features articles on the assessmentand management of childhood emergencies. This section is coordinated by Roger Barkin, MD, of the Rose Medical Center, Denver, Colorado. 13 August 1990; FINAL SUBMISSION RECEIVED: 16 November 1990; 0736-4679/91 $3.00 + .OO 12 December 1990 27
28
Michael
Table 1. Causes of Facial Nerve Disorders Seen over 20 Years
in 1999 Patients Patients
Cause Bell’s Palsy Herpes zoster cephalicus Trauma Tumor Infection Hemifacial spasm Central nervous system (axial) disease Other Tumor suspect Total
No.
%
1082 146 375 127 78 45 21 41 12
55 7 19 6 4 2 1 2 1
1989
100
Used with permission from May, Disorders of the facial nerve. In: ScottBrown’s Otolaryngology, vol 3, 5th ed. London: Butterworths; 1967:560-
J. Williams
reflex test, taste testing (the latter is difficult in young patients) and evoked electromyography if necessary. The role of steroids in the acute phase of traumatic facial paralysis management is controversial with no clear consensus of opinion (7,8). Although Bell’s palsy can present acutely with a sudden onset of complete facial paralysis, this case did not demonstrate some of the common features of Bell’s palsy. There were no reported viral prodromal symptoms, which are reported in 60% of cases of Bell’s palsy (6). Neither was there any complaint of pain around the ear (50% of cases) or facial numbness (40% of cases), reported in Bell’s palsy. Taste changes are difficult to interpret in younger patients.
601.
CONCLUSION
study to evaluate the long-term results of nonoperative management of traumatic facial nerve paralysis, suggested a limited role for surgery in closed traumatic facial paralysis. Although the paralysis in this case resolved spontaneously, further investigations at the time of presentation should be considered. May (6) stressed the importance of good history taking followed by a careful physical examination complemented by special tests where indicated. He advocates tests for hearing assessment, tear production (the Schirmer test), the stapedius
Blunt trauma to the facial nerve distal to the stylomastoid foramen is rare. The patient should be referred to an otorhinolaryngologist for further assessment. Further investigations can help to establish the precise site of the lesion to the nerve. There is no clear consensus of opinion about the benefits of steroids in nerve injury caused by blunt trauma. Acknowledgments - Dr. M. May, Department of Otorhinolaryngology, University of Pittsburgh, and Mrs. C. Wengraf, Consultant ENT Surgeon, Hull Royal Infirmary, England.
REFERENCES 1. May M. Trauma to the facial nerve. In: May M, ed. The facial nerve. New York: Thieme; 1986:422. 2. Ylikiski J. Facial palsy after temporal bone fracture. Laryngol Otol. 1988;102:298-303. 3. Schubiger 0, Valavanis A, Stuckman G, Antonucci F. Temporal bone fractures and their complications: examination with high resolution C.T. Neuroradiology. 1986:28:93-9. 4. Brodsky L, Eviatar A, Daniller A. Post traumatic facial nerve paralysis: 3 cases of delayed temporal bone exploration with recovery. Laryngoscope. 1983;93:1560-5. 5. Maiman DJ, Cusick JF, Anderson AJ, Larson SJ. Non operative
management
of traumatic
facial
nerve
palsy.
Trauma.
1985:25:
644-8. 6. May
M. Disorders of the facial nerve. In: Kerr AG, ed. ScottBrown’s Otolaryngology. 5th ed. vol 3. London: Butterworths; 1987:560-601. 7. Prescott CA. Idiopathic facial nerve palsy in children and the effect of treatment with steroids. Int J Pediatr Otorhinolaryngol. 1987;13:257-64. 8. Stankiewicz JA. Steroids and idiopathic facial paralysis. Otolaryngo1 Head Neck Surg. 1983:91:672-7.
of Emergency
Medune,
Vol. 9, pp. 27-28,
BLUNT TRAUMA
Printed
1991
LEADING TO FACIAL Michael J. Williams,
Reprint
address:
Michael
INTRODUCTION Facial paralysis due to blunt injury to the facial nerve is rare. In a series of 268 patients with traumatic injuries to the facial nerve, evaluated between 1962 and 1983, May (1) described only 3 cases due to blunt trauma distal to the stylomastoid foramen. In 1986 he reported 375 cases of facial nerve disorders due to trauma, an incidence of 19% of all causes of facial nerve disorders in the series (Table l), with only 4 cases due to blunt trauma.
RECEIVED: ACCEFTED:
Press plc
NERVE PARALYSIS
Infirmary, Hull, England Medicine, Hull Royal
Infirmary.
Anlaby
Road.
DISCUSSION Facial nerve paralysis in children is well described; however, a search of the literature shows that extracranial blunt injury to the nerve distal to the stylomastoid foramen is uncommon (1). The majority of the cases involving external trauma leading to facial paralysis are associated with fractures of the temporal bone (2). Plain film skull x-ray studies usually offer little information; high resolution computed tomography (CT scan) can give an accurate localization of the fracture site (3). The timing of surgery to decompress or repair the nerve and the role of electrophysiological testing are controversial (4). Haiman (5). in a retrospective
CASE HISTORY
=
0 1991 Pergamon
thereafter his parents noticed that the child appeared to be making grimacing movements of his face. Later in the day they noticed he could not close his left eye normally. Examination the next morning revealed a lower motor neuron, complete facial palsy. Physical examination revealed no evidence of tenderness or bruising over the nerve, although the child said that it had been painful locally at the time of injury. There was no evidence of a basal skull fracture, Battle’s sign was absent, and the tympanic membrane looked normal. Plain film-ray examination showed no evidence of bony injury. Appropriate eye care was initiated. Follow up of the paralysis revealed complete resolution in three weeks without specific treatment.
c] Keywords - facial nerve; paralysis; blunt trauma
A 4-year-old boy gency Department to the left side of been accidentally
CopyrIght
MB, FRCS
Registrar in Accident and Emergency Medicine, Hull Royal J. Williams, MB, FRCS, Registrar in Accident and Emergency Hull, England, HU3 2JZ
0 Abstract - A case in a young child of blunt trauma to the facial nerve, distal to the stylomastoid foramen, is reported. Although the patient made an uneventful recovery, an understanding of the possible sites of iqjury of the facial nerve and further investigations available to aid diagnosis is important. This child was followed up in the Accident and Emergency Department, however, early referral of this rare condition to an otolaryngologist is advisable.
In the USA.
presented to the Accident and Emer(A&E) with a history of direct trauma his face 24 hours previously. He had kicked by an older sibling; shortly
Clinical Communications: Pediatrics features articles on the assessmentand management of childhood emergencies. This section is coordinated by Roger Barkin, MD, of the Rose Medical Center, Denver, Colorado. 13 August 1990; FINAL SUBMISSION RECEIVED: 16 November 1990; 0736-4679/91 $3.00 + .OO 12 December 1990 27
28
Michael
Table 1. Causes of Facial Nerve Disorders Seen over 20 Years
in 1999 Patients Patients
Cause Bell’s Palsy Herpes zoster cephalicus Trauma Tumor Infection Hemifacial spasm Central nervous system (axial) disease Other Tumor suspect Total
No.
%
1082 146 375 127 78 45 21 41 12
55 7 19 6 4 2 1 2 1
1989
100
Used with permission from May, Disorders of the facial nerve. In: ScottBrown’s Otolaryngology, vol 3, 5th ed. London: Butterworths; 1967:560-
J. Williams
reflex test, taste testing (the latter is difficult in young patients) and evoked electromyography if necessary. The role of steroids in the acute phase of traumatic facial paralysis management is controversial with no clear consensus of opinion (7,8). Although Bell’s palsy can present acutely with a sudden onset of complete facial paralysis, this case did not demonstrate some of the common features of Bell’s palsy. There were no reported viral prodromal symptoms, which are reported in 60% of cases of Bell’s palsy (6). Neither was there any complaint of pain around the ear (50% of cases) or facial numbness (40% of cases), reported in Bell’s palsy. Taste changes are difficult to interpret in younger patients.
601.
CONCLUSION
study to evaluate the long-term results of nonoperative management of traumatic facial nerve paralysis, suggested a limited role for surgery in closed traumatic facial paralysis. Although the paralysis in this case resolved spontaneously, further investigations at the time of presentation should be considered. May (6) stressed the importance of good history taking followed by a careful physical examination complemented by special tests where indicated. He advocates tests for hearing assessment, tear production (the Schirmer test), the stapedius
Blunt trauma to the facial nerve distal to the stylomastoid foramen is rare. The patient should be referred to an otorhinolaryngologist for further assessment. Further investigations can help to establish the precise site of the lesion to the nerve. There is no clear consensus of opinion about the benefits of steroids in nerve injury caused by blunt trauma. Acknowledgments - Dr. M. May, Department of Otorhinolaryngology, University of Pittsburgh, and Mrs. C. Wengraf, Consultant ENT Surgeon, Hull Royal Infirmary, England.
REFERENCES 1. May M. Trauma to the facial nerve. In: May M, ed. The facial nerve. New York: Thieme; 1986:422. 2. Ylikiski J. Facial palsy after temporal bone fracture. Laryngol Otol. 1988;102:298-303. 3. Schubiger 0, Valavanis A, Stuckman G, Antonucci F. Temporal bone fractures and their complications: examination with high resolution C.T. Neuroradiology. 1986:28:93-9. 4. Brodsky L, Eviatar A, Daniller A. Post traumatic facial nerve paralysis: 3 cases of delayed temporal bone exploration with recovery. Laryngoscope. 1983;93:1560-5. 5. Maiman DJ, Cusick JF, Anderson AJ, Larson SJ. Non operative
management
of traumatic
facial
nerve
palsy.
Trauma.
1985:25:
644-8. 6. May
M. Disorders of the facial nerve. In: Kerr AG, ed. ScottBrown’s Otolaryngology. 5th ed. vol 3. London: Butterworths; 1987:560-601. 7. Prescott CA. Idiopathic facial nerve palsy in children and the effect of treatment with steroids. Int J Pediatr Otorhinolaryngol. 1987;13:257-64. 8. Stankiewicz JA. Steroids and idiopathic facial paralysis. Otolaryngo1 Head Neck Surg. 1983:91:672-7.