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Facial nerve paresis involving passenger airbag deployment: A case report
The
Journal of Emergency Medicine. Vol 15. No 4. pp ,i75---176, 1g97 Copyright 0 1997 Eisewer Science Lnc. Printed in the USA. All righti reserved 0936~4679/9’
ELSEVIER
s 17.00
a .oo
PII SO736-4679(97)00075-9
FACIAL
NERVE
PARESIS
INVOLVWG A CASE
James R. Bedell,
PAS!BWER REPORT
MD,*
AHWAG
and Vinod Malik, MDT
*Emergency Medical Services Institute, Catholic Medical Center, Queens, New York tDepat?ment of Anesthesiology, Lincoln Hospital and Mental Health Center, Valhalla, New York Reprint Address: James R. Bedell, MD, OtTice of Medical Affairs, New York City Fire Department, 250 Livingston Street, Brooklyn, NY 11201
U Abstract-The case of a 32-yr-old woman who developed transient facial nerve paresis following deployment of the passenger airbag is presented. Although a wide range of injuries including fatalities have occurred, this case represents a unique type of injury following passenger airbag 0 1997 Elsevier Science Inc. deployment.
individuals in vehicles without airbags (5,6). We report the case of facial nerve paresis involving passenger airbag deployment.
U Keywords-airbag; facial nerve; paralysis; paresis; motor vehicle injury; Bell’s palsy
A healthy, 32-yr-old woman, 5 feet 2 inches and 120 pounds, was the seat-belted passenger of the car when she was involved in a collision that impacted the side of the vehicle. Impact occurred at a speed of approximately 25 mph. The patient’s automobile was equipped with seat belts and front-located driver and passenger airbags, which did employ on contact. The patient was brought via emergency medical services to the emergency department (ED) in full spinal immobilization. The patient complained of an inability to close the right eye and a ringing in the right ear. She denied loss of consciousness, headache, nausea, vomiting, or blurring of vision. The past medical history was noncontributory, and she was taking no medications. On physical examination, the vital signs were normal, with no deformity of the head and neck, and the cervical spine was nontender. There were no visible skin abrasions or contusions of the face and neck. Further physical examination revealed an inability to completely close the right eye and right facial droop, with sparing of the forehead muscles. The patient
CASE
INTRODUCTION
Since airbags were first introduced in passenger automobiles approximately 20 yr ago (l), the percentage of automobiles equipped with airbags is increasing. As reported by the Institute for Highway Safety, the percentage of new cars equipped with driver’s airbag was expected to increase to 91% in the 1994 model year (2). A new method of providing additional protection is a side airbag located over the side window or door. These too have been associated with injuries. Although the rate of fatal crashes has been reported to be reduced by 16% in automobiles equipped with airbags (3), more airbagrelated injuries are being reported (4). However, the current literature suggests that individuals protected by airbag-equipped vehicles sustain less severe injuries than
REPORT
Clinical Communications (Adults) is coordinatedby Ron M. Walls, MD, of Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts RECEIVED: 12 August 1996; FINAL ACCEFIXD:13 November 1996
SUBMISSION RECEIVED:
29 October 1996; 475
J. R. Bedell and V. Malik
had no altered taste sensations,as tested by differentiating sweet (sugar), salt, and bitter (juice from a lemon). Cervical, thoracolumbar, and sacral spine radiographs showed no fractures. Computed tomography scansof the head and face were normal. The patient was given Decadron@4 mg intravenously and discharged on nonsteroidal anti-inflammatory drugs. The ringing of the ears subsided after 6-8 h, and the patient had neither hyperacusisnor residual hearing loss. The patient was interviewed by telephoneevery 2 wk for 3 mo. By the third month, she had no residual paresis of the involved facial nerve. DISCUSSION Airbags have been associatedwith ocular (7-9), upper extremity (lo), lower extremity (1 l), occult abdominal (l), and chest (12) injuries. A detailed statistical analysis of driver fatalities in cars with airbags over an 8-yr period has been described by Lund and Ferguson (3). The classification type of crash, vehicle, and driver factors and the location of impact analysis showed a 26% reduction in fatalities of an-bag-equippedvehicles. Our patient had an isolated facial nerve paresis. We
believe the site of injury occurred (a) distal to the temporal branch of the facial nerve, in or near the parotid gland; or (b) in the facial canal lesion, sparing the function of the forehead muscle, as may occur in some lesions distal to the stylomastoid foramen that do not involve all branchesof the facial nerve. Our patient had a typical peripheral 7th nerve injury, as in Bell’s palsy. Both the stylomastoid foremen and the distal facial canal are very well protected, making this site of injury less likely. Becausethe foreheadwas spared,the nerve injury must have occurred distal to the temporal branch of the facial nerve, in or near the parotid. Although the exact mechanism for this injury is not known, we hypothesize a traumatic neuropraxia. The impact of the airbag was from the front of the patient, and the injury was isolated to the right side of the face. The deployment of the airbag probably causedthe injury, but the patient also may have struck the passenger’sside door or window. Her sitting position or having her head turned to the left could account for the fact that the right side was preferentially injured. Airbag deployment velocity, which can be 160-320 km/h (lo), may have contused the nerve, causing the mentioned symptoms. This injury is rather unique and has not been reported in the medical literature previously.
REFERENCES 1. Augenstein JS, Digges RH, Lambardo LV, Perdeck EB, Stratton JE, Mallians AC, Quigley CV, Craythome AR, Young PE. Occult abdominal injuries to airbag-protected crash victims: A challenge to trauma systems.Trauma. 1995;38:502-8. 2. Irkwmce Institutefor Highway Safety. Airbags in pmspecdvestatus mport [specialissue].InsurInst Highway Safety.1993;28(11):1-8. 3. Lund KA, Ferguson SA. Driver fatalities in 1985-1993 cars with airbags. Trauma. 1995;38:469-75. 4. Smock WS, Nichols GR. Airbag module covers injuries. Trauma. 1995;38:489-93. 5. Insurance Institute for Highway Safety. Close study of injuries yields concern, not alarm. Status Rep. 1993;28:1. 6. Huelke DF, Moore JL, Ostriim M. Airbag injuries and occupant protection. Trauma. 1992;33:489-93.
7. Mishler KE. Hyphema caused by airbag. Arch Opthalmol. 1991; 109:1635. 8. Larkin GL. Airbag-mediated comeal injury. Am J Emerg Med. 1991;9:444. 9. Rimmer S, Schuler JD. Severe ocular trauma from driver’+side airbag. Arch Ophthalmol. 1991;109:774. 10. Huelke DF, Moore JR, Camptone TW. Upper extremity injuries related to airbag deployments. Trauma. 1995;38:482-7. 11. Burgess AR, Dischinger PC, O’Quinn TD. Lower extremity injuries in drivers of airbag-equipped automobiles: Clinical and crash reconstruction correlations. Trauma. 1995;38:50916. 12. Lancaster GI, Defiance JH, Borruso JJ. Airbag-associatedrupture of right atrium. N Engl J Med. 1993;328:358.
Journal of Emergency Medicine. Vol 15. No 4. pp ,i75---176, 1g97 Copyright 0 1997 Eisewer Science Lnc. Printed in the USA. All righti reserved 0936~4679/9’
ELSEVIER
s 17.00
a .oo
PII SO736-4679(97)00075-9
FACIAL
NERVE
PARESIS
INVOLVWG A CASE
James R. Bedell,
PAS!BWER REPORT
MD,*
AHWAG
and Vinod Malik, MDT
*Emergency Medical Services Institute, Catholic Medical Center, Queens, New York tDepat?ment of Anesthesiology, Lincoln Hospital and Mental Health Center, Valhalla, New York Reprint Address: James R. Bedell, MD, OtTice of Medical Affairs, New York City Fire Department, 250 Livingston Street, Brooklyn, NY 11201
U Abstract-The case of a 32-yr-old woman who developed transient facial nerve paresis following deployment of the passenger airbag is presented. Although a wide range of injuries including fatalities have occurred, this case represents a unique type of injury following passenger airbag 0 1997 Elsevier Science Inc. deployment.
individuals in vehicles without airbags (5,6). We report the case of facial nerve paresis involving passenger airbag deployment.
U Keywords-airbag; facial nerve; paralysis; paresis; motor vehicle injury; Bell’s palsy
A healthy, 32-yr-old woman, 5 feet 2 inches and 120 pounds, was the seat-belted passenger of the car when she was involved in a collision that impacted the side of the vehicle. Impact occurred at a speed of approximately 25 mph. The patient’s automobile was equipped with seat belts and front-located driver and passenger airbags, which did employ on contact. The patient was brought via emergency medical services to the emergency department (ED) in full spinal immobilization. The patient complained of an inability to close the right eye and a ringing in the right ear. She denied loss of consciousness, headache, nausea, vomiting, or blurring of vision. The past medical history was noncontributory, and she was taking no medications. On physical examination, the vital signs were normal, with no deformity of the head and neck, and the cervical spine was nontender. There were no visible skin abrasions or contusions of the face and neck. Further physical examination revealed an inability to completely close the right eye and right facial droop, with sparing of the forehead muscles. The patient
CASE
INTRODUCTION
Since airbags were first introduced in passenger automobiles approximately 20 yr ago (l), the percentage of automobiles equipped with airbags is increasing. As reported by the Institute for Highway Safety, the percentage of new cars equipped with driver’s airbag was expected to increase to 91% in the 1994 model year (2). A new method of providing additional protection is a side airbag located over the side window or door. These too have been associated with injuries. Although the rate of fatal crashes has been reported to be reduced by 16% in automobiles equipped with airbags (3), more airbagrelated injuries are being reported (4). However, the current literature suggests that individuals protected by airbag-equipped vehicles sustain less severe injuries than
REPORT
Clinical Communications (Adults) is coordinatedby Ron M. Walls, MD, of Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts RECEIVED: 12 August 1996; FINAL ACCEFIXD:13 November 1996
SUBMISSION RECEIVED:
29 October 1996; 475
J. R. Bedell and V. Malik
had no altered taste sensations,as tested by differentiating sweet (sugar), salt, and bitter (juice from a lemon). Cervical, thoracolumbar, and sacral spine radiographs showed no fractures. Computed tomography scansof the head and face were normal. The patient was given Decadron@4 mg intravenously and discharged on nonsteroidal anti-inflammatory drugs. The ringing of the ears subsided after 6-8 h, and the patient had neither hyperacusisnor residual hearing loss. The patient was interviewed by telephoneevery 2 wk for 3 mo. By the third month, she had no residual paresis of the involved facial nerve. DISCUSSION Airbags have been associatedwith ocular (7-9), upper extremity (lo), lower extremity (1 l), occult abdominal (l), and chest (12) injuries. A detailed statistical analysis of driver fatalities in cars with airbags over an 8-yr period has been described by Lund and Ferguson (3). The classification type of crash, vehicle, and driver factors and the location of impact analysis showed a 26% reduction in fatalities of an-bag-equippedvehicles. Our patient had an isolated facial nerve paresis. We
believe the site of injury occurred (a) distal to the temporal branch of the facial nerve, in or near the parotid gland; or (b) in the facial canal lesion, sparing the function of the forehead muscle, as may occur in some lesions distal to the stylomastoid foramen that do not involve all branchesof the facial nerve. Our patient had a typical peripheral 7th nerve injury, as in Bell’s palsy. Both the stylomastoid foremen and the distal facial canal are very well protected, making this site of injury less likely. Becausethe foreheadwas spared,the nerve injury must have occurred distal to the temporal branch of the facial nerve, in or near the parotid. Although the exact mechanism for this injury is not known, we hypothesize a traumatic neuropraxia. The impact of the airbag was from the front of the patient, and the injury was isolated to the right side of the face. The deployment of the airbag probably causedthe injury, but the patient also may have struck the passenger’sside door or window. Her sitting position or having her head turned to the left could account for the fact that the right side was preferentially injured. Airbag deployment velocity, which can be 160-320 km/h (lo), may have contused the nerve, causing the mentioned symptoms. This injury is rather unique and has not been reported in the medical literature previously.
REFERENCES 1. Augenstein JS, Digges RH, Lambardo LV, Perdeck EB, Stratton JE, Mallians AC, Quigley CV, Craythome AR, Young PE. Occult abdominal injuries to airbag-protected crash victims: A challenge to trauma systems.Trauma. 1995;38:502-8. 2. Irkwmce Institutefor Highway Safety. Airbags in pmspecdvestatus mport [specialissue].InsurInst Highway Safety.1993;28(11):1-8. 3. Lund KA, Ferguson SA. Driver fatalities in 1985-1993 cars with airbags. Trauma. 1995;38:469-75. 4. Smock WS, Nichols GR. Airbag module covers injuries. Trauma. 1995;38:489-93. 5. Insurance Institute for Highway Safety. Close study of injuries yields concern, not alarm. Status Rep. 1993;28:1. 6. Huelke DF, Moore JL, Ostriim M. Airbag injuries and occupant protection. Trauma. 1992;33:489-93.
7. Mishler KE. Hyphema caused by airbag. Arch Opthalmol. 1991; 109:1635. 8. Larkin GL. Airbag-mediated comeal injury. Am J Emerg Med. 1991;9:444. 9. Rimmer S, Schuler JD. Severe ocular trauma from driver’+side airbag. Arch Ophthalmol. 1991;109:774. 10. Huelke DF, Moore JR, Camptone TW. Upper extremity injuries related to airbag deployments. Trauma. 1995;38:482-7. 11. Burgess AR, Dischinger PC, O’Quinn TD. Lower extremity injuries in drivers of airbag-equipped automobiles: Clinical and crash reconstruction correlations. Trauma. 1995;38:50916. 12. Lancaster GI, Defiance JH, Borruso JJ. Airbag-associatedrupture of right atrium. N Engl J Med. 1993;328:358.