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Posttraumatic delayed facial nerve palsy
American Journal of Emergency Medicine (2008) 26, 115.e1–115.e2
www.elsevier.com/locate/ajem
Case Report Posttraumatic delayed facial nerve palsy
Abstract Up to 5% of all facial nerve palsies are due to trauma, with ipsilateral Bell's palsy the most common injury. Facial nerve injury is often due to fracture of the temporal bone with resultant compression of the nerve or complete transection. Less commonly, mandibular fractures can present with a concomitant facial nerve injury. In cases where the nerve injury is incomplete or delayed, prognosis is excellent. When the facial nerve is completely transected, prompt surgical intervention is required for the best cosmetic outcome. Here we present a case of a delayed presentation of an ipsilateral facial nerve injury and discuss the diagnostic and management options. A 28-year-old woman fell down 6 steps after losing her footing. She landed on all fours, with her chin “smacking the ground first.” She presented to the emergency department (ED) with a 2-cm chin laceration and complaints of ear, jaw, and occipital head and neck discomfort. She also had sharp pains on both sides of her upper jaw and difficulty fully opening her mouth. She denied losing consciousness, vision changes, focal numbness, paresthesias, or weakness. Other than her head and neck complaints, she denied any other injury. She had no significant past medical, surgical, or social history. She arrived to the ED and was immediately placed in a cervical collar. Her vital signs on presentation were all within normal limits. On physical examination, she appeared to be in mild distress. Her head examination was notable for tenderness to light palpation along both temporomandibular joints (TMJs) and she was unable to open her mouth beyond 1.5 cm. A tongue depressor test was not performed. She had a 2-cm linear laceration at the bottom of her chin, which was no longer bleeding. The wound appeared clean and bone was not visualized. Her neck was tender along the superior cervical spine. There was no crepitus or step off. Her eyes, ears, nose, and mouth were unremarkable. Her neurologic examination was fully intact. While in the ED, she had a cervical spine series and a panoramic x-ray, both of which were read as negative for bony injury. Her laceration was repaired and she was given ibuprofen and 2 tablets of acetaminophen/ oxycodone (325/5 mg) for pain. She was instructed to return in 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
5 to 7 days for suture removal and to use an ice pack for jaw and chin pain and swelling. She was additionally prescribed narcotics for pain and advised to also take ibuprofen as needed. One week later, she returned for suture removal, still complaining of bilateral upper jaw pain and difficulty chewing. She also noted persistent right ear pain and intermittent headaches. The day before, she developed decreased sensation along the entire right side of her face and tongue. Her physical examination was notable for bilateral TMJ point tenderness (R N L) with no palpable bony deformity. Her right external auditory canal was edematous along the inferior and lateral walls, with slight erythema. The tympanic membrane was normal and there was no drainage from the ear. The patient still complained of pain when opening her mouth and her ability to open her mouth was still limited to 1.5 cm. There was no visible malocclusion, but the patient also had this complaint. Her chin laceration was well healed and the sutures were removed. Her neurologic examination was notable for the development of a HouseBrackmann grade IV right-sided ipsilateral Bell's palsy [1]. Computed tomographic imaging of the patient's head was
Fig. 1 Computed tomography in axial plane: crescent-shaped fracture fragment of the glenoid fossa of the TMJ is displaced cephalad into the infratemporal space.
115.e2
Fig. 2 Computed tomography in coronal plane: right mandibular condyle is displaced superiorly with resultant fracture of the glenoid fossa.
obtained, which revealed a unilateral fracture of the right condylar fossa region, with superior displacement of the right mandibular condyle (Figs. 1 and 2). Posttraumatic nerve palsy accounts for up to 5% of all cases of facial paralysis, with unilateral palsies nearly 1000 times more common than bilateral palsies [2,3]. The most common cause of unilateral facial paralysis is due to fracture of the temporal bone, with either compression placed on the facial nerve by displacement of bony fragments, soft tissue edema, and localized hematoma formation, or traumatic disruption of the nerve. The rarer bilateral facial palsies result from either significant head trauma, with associated bilateral temporal bone fractures, or bilateral mandibular fractures. In cases with bilateral temporal bone fractures, the head injury is often associated with other life-threatening injuries, and most patients die before the facial palsy is identified [4]. Bilateral mandibular fractures are exceedingly rare, with only 3 cases reported in the literature [3,5,6]. Development of a facial nerve palsy after trauma has prognostic implications: With immediate onset, the nerve is either completely lacerated or contused at the fracture site. With delayed presentations (typically 4-5 days after injury), delayed arterial spasm, thrombosis, or external compression from bony fragments or soft tissue edema result in partial or complete degeneration of the facial nerve. Evaluation of patients with traumatic nerve injuries includes high-resolution computed tomographic imaging, audiologic testing, and electromyography. Electrodiagnostic studies can differentiate if the damage is due to neuropraxia, axonotmesis, or neurotmesis. Neuropraxia typically occurs with compression injuries, where the myelin sheath is damaged but the axon is spared. The majority resolve rapidly and completely. Axonotmesis occurs when the axon is transected but the nerve sheath remains intact. Typically, Wallerian degeneration occurs approximately 7 days after injury in the distal axon.
Case Report Upon regeneration of the distal axon within the intact sheath, recovery ensues. Neurotmesis, or complete transaction of the nerve, is the worst of the 3 injury patterns and requires surgical management [3]. Surgical intervention includes decompression via evacuation of hematomas and excision of impinging fractured bone and fibrotic tissue surrounding the facial nerve [7,8]. Facial nerve repair is achieved by reanastomosis of the severed ends or, in cases with significant loss of nerve tissue, cable grafts using the great auricular nerve at the Erb point, the sural nerve, or the cervical plexus (C3, C4) as donor sites [9]. In cases of incomplete or delayed facial nerve palsy, methylprednisolone (2 mg/kg per day) for 3 weeks has also been shown to be of some benefit [9]. In the ED setting, the evaluating physician's primary focus should be to exclude other, more serious, traumatic injuries. In cases of a completely severed facial nerve, other injuries will typically be identified. For delayed presentations, such as this case, prompt referral (within 2 weeks of injury) to an oral maxillofacial surgeon is appropriate. Immediate consultation is not necessary, because most patients will require audiologic and electromyographic testing to determine the extent of facial nerve injury. The primary goal of the emergency physician is to prevent additional complications. Incomplete closure of the eye can lead to corneal abrasions and keratitis sicca. Artificial tears and Lacrilube for nighttime use must be prescribed. Brigitte M. Baumann MD, MSCE Jennifer Jarecki DO Department of Emergency Medicine UMDNJ-RWJMS at Camden Camden, NJ 08103, USA E-mail address: [email protected] doi:10.1016/j.ajem.2007.07.017
References [1] House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7. [2] Steenerson RL. Bilateral facial paralysis. Am J Otol 1986;7(2):99-103. [3] Li J, Goldberg G, Munin MC, Wagner A, Zafonte R. Post-traumatic bilateral facial palsy: a case report and literature review. Brain Inj 2004; 18(3):315-20. [4] Price T, Fife DG. Bilateral simultaneous facial nerve palsy. J Laryngol Otol 2002;116(1):46-8. [5] Kumar S, Gupta R. Simultaneous bilateral facial palsy as a result of isolated mandibular fractures. Int J Oral Maxillofac Surg 2006;35(12): 1156-9. [6] Goin DW. Facial nerve paralysis secondary to mandibular fracture. Laryngoscope 1980;90(11 Pt 1):1777-85. [7] Ulug T, Arif Ulubil S. Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures. Am J Otolaryngol 2005;26(4):230-8. [8] Malik TH, Kelly G, Ahmed A, Saeed SR, Ramsden RT. A comparison of surgical techniques used in dynamic reanimation of the paralyzed face. Otol Neurotol 2005;26(2):284-91. [9] Darrouzet V, Duclos JY, Liguoro D, Truilhe Y, De Bonfils C, Bebear JP. Management of facial paralysis resulting from temporal bone fractures: our experience in 115 cases. Otolaryngol Head Neck Surg 2001;125(1):77-84.
www.elsevier.com/locate/ajem
Case Report Posttraumatic delayed facial nerve palsy
Abstract Up to 5% of all facial nerve palsies are due to trauma, with ipsilateral Bell's palsy the most common injury. Facial nerve injury is often due to fracture of the temporal bone with resultant compression of the nerve or complete transection. Less commonly, mandibular fractures can present with a concomitant facial nerve injury. In cases where the nerve injury is incomplete or delayed, prognosis is excellent. When the facial nerve is completely transected, prompt surgical intervention is required for the best cosmetic outcome. Here we present a case of a delayed presentation of an ipsilateral facial nerve injury and discuss the diagnostic and management options. A 28-year-old woman fell down 6 steps after losing her footing. She landed on all fours, with her chin “smacking the ground first.” She presented to the emergency department (ED) with a 2-cm chin laceration and complaints of ear, jaw, and occipital head and neck discomfort. She also had sharp pains on both sides of her upper jaw and difficulty fully opening her mouth. She denied losing consciousness, vision changes, focal numbness, paresthesias, or weakness. Other than her head and neck complaints, she denied any other injury. She had no significant past medical, surgical, or social history. She arrived to the ED and was immediately placed in a cervical collar. Her vital signs on presentation were all within normal limits. On physical examination, she appeared to be in mild distress. Her head examination was notable for tenderness to light palpation along both temporomandibular joints (TMJs) and she was unable to open her mouth beyond 1.5 cm. A tongue depressor test was not performed. She had a 2-cm linear laceration at the bottom of her chin, which was no longer bleeding. The wound appeared clean and bone was not visualized. Her neck was tender along the superior cervical spine. There was no crepitus or step off. Her eyes, ears, nose, and mouth were unremarkable. Her neurologic examination was fully intact. While in the ED, she had a cervical spine series and a panoramic x-ray, both of which were read as negative for bony injury. Her laceration was repaired and she was given ibuprofen and 2 tablets of acetaminophen/ oxycodone (325/5 mg) for pain. She was instructed to return in 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
5 to 7 days for suture removal and to use an ice pack for jaw and chin pain and swelling. She was additionally prescribed narcotics for pain and advised to also take ibuprofen as needed. One week later, she returned for suture removal, still complaining of bilateral upper jaw pain and difficulty chewing. She also noted persistent right ear pain and intermittent headaches. The day before, she developed decreased sensation along the entire right side of her face and tongue. Her physical examination was notable for bilateral TMJ point tenderness (R N L) with no palpable bony deformity. Her right external auditory canal was edematous along the inferior and lateral walls, with slight erythema. The tympanic membrane was normal and there was no drainage from the ear. The patient still complained of pain when opening her mouth and her ability to open her mouth was still limited to 1.5 cm. There was no visible malocclusion, but the patient also had this complaint. Her chin laceration was well healed and the sutures were removed. Her neurologic examination was notable for the development of a HouseBrackmann grade IV right-sided ipsilateral Bell's palsy [1]. Computed tomographic imaging of the patient's head was
Fig. 1 Computed tomography in axial plane: crescent-shaped fracture fragment of the glenoid fossa of the TMJ is displaced cephalad into the infratemporal space.
115.e2
Fig. 2 Computed tomography in coronal plane: right mandibular condyle is displaced superiorly with resultant fracture of the glenoid fossa.
obtained, which revealed a unilateral fracture of the right condylar fossa region, with superior displacement of the right mandibular condyle (Figs. 1 and 2). Posttraumatic nerve palsy accounts for up to 5% of all cases of facial paralysis, with unilateral palsies nearly 1000 times more common than bilateral palsies [2,3]. The most common cause of unilateral facial paralysis is due to fracture of the temporal bone, with either compression placed on the facial nerve by displacement of bony fragments, soft tissue edema, and localized hematoma formation, or traumatic disruption of the nerve. The rarer bilateral facial palsies result from either significant head trauma, with associated bilateral temporal bone fractures, or bilateral mandibular fractures. In cases with bilateral temporal bone fractures, the head injury is often associated with other life-threatening injuries, and most patients die before the facial palsy is identified [4]. Bilateral mandibular fractures are exceedingly rare, with only 3 cases reported in the literature [3,5,6]. Development of a facial nerve palsy after trauma has prognostic implications: With immediate onset, the nerve is either completely lacerated or contused at the fracture site. With delayed presentations (typically 4-5 days after injury), delayed arterial spasm, thrombosis, or external compression from bony fragments or soft tissue edema result in partial or complete degeneration of the facial nerve. Evaluation of patients with traumatic nerve injuries includes high-resolution computed tomographic imaging, audiologic testing, and electromyography. Electrodiagnostic studies can differentiate if the damage is due to neuropraxia, axonotmesis, or neurotmesis. Neuropraxia typically occurs with compression injuries, where the myelin sheath is damaged but the axon is spared. The majority resolve rapidly and completely. Axonotmesis occurs when the axon is transected but the nerve sheath remains intact. Typically, Wallerian degeneration occurs approximately 7 days after injury in the distal axon.
Case Report Upon regeneration of the distal axon within the intact sheath, recovery ensues. Neurotmesis, or complete transaction of the nerve, is the worst of the 3 injury patterns and requires surgical management [3]. Surgical intervention includes decompression via evacuation of hematomas and excision of impinging fractured bone and fibrotic tissue surrounding the facial nerve [7,8]. Facial nerve repair is achieved by reanastomosis of the severed ends or, in cases with significant loss of nerve tissue, cable grafts using the great auricular nerve at the Erb point, the sural nerve, or the cervical plexus (C3, C4) as donor sites [9]. In cases of incomplete or delayed facial nerve palsy, methylprednisolone (2 mg/kg per day) for 3 weeks has also been shown to be of some benefit [9]. In the ED setting, the evaluating physician's primary focus should be to exclude other, more serious, traumatic injuries. In cases of a completely severed facial nerve, other injuries will typically be identified. For delayed presentations, such as this case, prompt referral (within 2 weeks of injury) to an oral maxillofacial surgeon is appropriate. Immediate consultation is not necessary, because most patients will require audiologic and electromyographic testing to determine the extent of facial nerve injury. The primary goal of the emergency physician is to prevent additional complications. Incomplete closure of the eye can lead to corneal abrasions and keratitis sicca. Artificial tears and Lacrilube for nighttime use must be prescribed. Brigitte M. Baumann MD, MSCE Jennifer Jarecki DO Department of Emergency Medicine UMDNJ-RWJMS at Camden Camden, NJ 08103, USA E-mail address: [email protected] doi:10.1016/j.ajem.2007.07.017
References [1] House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7. [2] Steenerson RL. Bilateral facial paralysis. Am J Otol 1986;7(2):99-103. [3] Li J, Goldberg G, Munin MC, Wagner A, Zafonte R. Post-traumatic bilateral facial palsy: a case report and literature review. Brain Inj 2004; 18(3):315-20. [4] Price T, Fife DG. Bilateral simultaneous facial nerve palsy. J Laryngol Otol 2002;116(1):46-8. [5] Kumar S, Gupta R. Simultaneous bilateral facial palsy as a result of isolated mandibular fractures. Int J Oral Maxillofac Surg 2006;35(12): 1156-9. [6] Goin DW. Facial nerve paralysis secondary to mandibular fracture. Laryngoscope 1980;90(11 Pt 1):1777-85. [7] Ulug T, Arif Ulubil S. Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures. Am J Otolaryngol 2005;26(4):230-8. [8] Malik TH, Kelly G, Ahmed A, Saeed SR, Ramsden RT. A comparison of surgical techniques used in dynamic reanimation of the paralyzed face. Otol Neurotol 2005;26(2):284-91. [9] Darrouzet V, Duclos JY, Liguoro D, Truilhe Y, De Bonfils C, Bebear JP. Management of facial paralysis resulting from temporal bone fractures: our experience in 115 cases. Otolaryngol Head Neck Surg 2001;125(1):77-84.