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 manage-
ment 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 tender-
ness 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
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 House-
Brackmann grade IV right-sided ipsilateral Bell's palsy [1].
Computed tomographic imaging of the patient's head was
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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.
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American Journal of Emergency Medicine (2008) 26, 115.e1–115.e2