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Delayed Facial Palsy After Head Injury J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.40.4.342 on 1 April 1977. Downloaded from Journal ofNeurology, Neurosurgery, andPsychiatry, 1977, 40, 342-350 Delayed facial palsy after head injury K. PUVANENDRAN, M. VITHARANA, AND P. K. WONG From the University Department ofMedicine, and the Department ofOtorhinolaryngology, Singapore General Hospital, Singapore SUMMARY Where facial palsy follows head injury after many days, the mechanism is not clear, and there has been no detailed study on this condition. In this prospective study, an attempt is made to estimate this complication of head injury, and to study its pathogenesis, natural history, prognosis, and sequelae which differ markedly from Bell's palsy. It has a much worse prognosis and so surgical decompression should be considered early in this condition. The facial nerve is the motor cranial nerve which is studies, for prediction of prognosis at a time when most commonly affected in closed head injuries surgical intervention seems most advantageous. (Turner, 1943). In facial palsy which immediately follows a head injury, the mechanism is obvious, but Patients and methods Protected by copyright. it is not clear when the facial palsy follows the head injury after many days (Potter and Braakman, 1976). During the period May 1974-April 1975, there were Traumatic facial palsy has received much attention 6304 cases of head injury admitted to government but few authors distinguish between immediate and hospitals in Singapore. The chief criterion for delayed palsy. admission to hospital was the occurrence of traumatic Turner (1944) studied a selected group of war-time amnesia or unconsciousness, indicating concussion head injuries from a military hospital for head of the brain. Knowing that most post-traumatic injuries, and found an incidence of 2.2 % developing facial palsies were associated with bleeding ears a delayed facial palsy. Potter (1964), however, (Turner, 1944; Briggs and Potter, 1967), all cases of estimated the incidence of this complication of head bleeding ear after such closed head injury were injury as about 0.6 %. Both authors have cautioned studied from the day of head injury to the evolution about the difficulty in detecting an immediate facial of the delayed facial palsy in some. Cases of bleeding palsy and which may result in wrong classification as ear referred for study were those where the bleeding delayed facial palsy. Turner's estimate of this was thought to come from the middle or inner ear. condition would appear to be high for this reason These cases were seen initially daily, and examined http://jnnp.bmj.com/ and because of the selected type of cases studied. clinically and by electrodiagnostic methods. This We studied these cases in detail clinically and took gave us an accurate indication of the exact time of advantage of electrodiagnostic methods (Puvanen- onset of the facial palsy, and allayed arguments as dran et al., 1977). Grove (1939), Turner (1944), and to whether these were in fact cases of immediate Miehlke (1973b) state that 80-90% of delayed facial palsy which was not obvious because of the facial palsies make a spontaneous and complete obtunded state of the patient immediately after the recovery. Our study shows results which are unlike head injury. these findings. We have tried to explain the patho- Every case of bleeding ear with facial palsy had on September 25, 2021 by guest. genesis of this condition, and also reviewed other radiographs of the skull, including special views to hypotheses on the causation of this palsy. show the petrous temporal bones on both sides. There is much disagreement about the precise Where no fracture was seen tomograms were place for surgical exploration of the injured nerve prepared. because of lack of knowledge of its natural history Cochlear, vestibular, and middle-ear functions and the lack of any method, including electrical were also studied in these cases in detail because of their close anatomical relation to the 7th nerve. Address for reprint requests: Dr K. Puvanendran, University Depart- ment of Medicine (1), Singapore General Hospital, Singapore 3, All patients had a detailed neurological examina- Republic of Singapore. tion with special regard to other cranial nerve palsy. Accepted 4 November 1976 The site of the lesion of the facial nerve was 342 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.40.4.342 on 1 April 1977. Downloaded from Delayedfacial palsy after head injury 343 ascertained by testing the function of its branches, Table 1 Delayedfacialpalsy such as lacrimation by the Shirmer test (Miehlke, Males Females Total 1973a), and taste function from the anterior two- 12 4 16 thirds of the homolateral side of the tongue, in Side ofPalsy Right Left (Bilateral) Total addition to the facial nerve proper. All patients had 9 10 (3) 19 Type ofPalsy Clinical Latent Total a complete or partial paralysis of muscles of 17 2 19 expression of the whole of one side of the face. The Clinical palsy Complete Partial Total 14 3 17 degree of paralysis was estimated visually as a Site of lesion in Geniculate Distal to Total percentage of the normal side (Taverner, 1955). This clinical palsy ganglion -chorda method was fairly consistent in studying the progress tympani of the palsy, but we often supplemented this with 10 7 17 photographs which made comparison easy. By comparison with the opposite side, the weakness was estimated as 25o%, 50%, 75%, 1000%, using the developed after a long delay, after the pain of the frontalis, orbicularis oculi, and orbicularis oris head injury had disappeared. muscles, and the average of these estimations was taken. We studied the orbicularis oculi, measuring SITE OF IMPACT the palpebral fissure and, on recovery of power, This was judged from the history and from external estimating how much more of the eyelash jutted out injuries. In nine cases the site of impact was around on attempting tight closure of the eye. We defined as the ear, in two it was over the mastoid bone, and in subclinical or latent palsy those cases with abnormal three over the occipital area. In each of these cases it electrical tests but without clinically evident palsy. was on the side of the facial palsy which also All cases were followed up to study the progression corresponded with the side of the bleeding ear. In Protected by copyright. of the facial palsy, the recovery, the development of the three cases who developed bilateral palsy, the site sequelae such as abnormal movement, the cosmetic of impact was only over one ear. result, and the patient's satisfaction with the recovery. SITE OF LESION Results In 10 cases the site of the lesion was found to be at the geniculate ganglion, and in these cases secretion Of the 6304 cases of head injuries admitted to the of tears, which is innervated by the greater superficial various hospitals, 39 had bleeding ears. Sixteen of petrosal nerve, was lost on the side of the lesion, these patients developed delayed facial palsy while with loss of taste sensation in the anterior two-thirds three were noted to have an immediate facial palsy at of that side of the tongue which is innervated by the time of injury. Three of these 16 patients had bilateral chorda tympani nerve. In seven cases the taste facial palsies, two of the latter each having a sensation and lacrymation were intact, and the lesion subclinical palsy as defined above. The incidence of was considered to be distal to the chorda tympani bleeding ears in these patients with closed head branch. injuries was 0.6 % and the incidence of delayed facial palsy 0.3 %. The chance of a case of bleeding ONSET http://jnnp.bmj.com/ ear developing a delayed facial palsy after head The delay in onset of facial palsy after head injury injury was 49 %. There was no case of delayed facial varied from two to 21 days (Fig. 1). In most cases palsy who did not have a bleeding ear after head the facial palsy came on between two and seven injury, except one patient who had bilateral facial days. In two instances the onset of delayed facial palsy but with bleeding from the right ear only. palsy was indicated by a sudden abnormal prolonga- There were 12 males and four females with ages tion in the terminal latency of facial muscle evoked anging from 9 to 58 years (Table 1). Eleven patients response, previously shown to be normal in the were involved in traffic accidents while five had serial electrodiagnostic tests. In both instances, the on September 25, 2021 by guest. fallen. In 14 cases the facial palsy was complete, in subclinical facial palsy occurred 13 to 14 days after three it was partial, while two patients had sub- the onset of a clinically obvious facial palsy on the clinical palsy. One of the cases of complete facial opposite side, a delay of 16 to 19 days after head palsy was partial at first, and it took six days before injury. The cases of conduction block had a delayed it became complete. onset of seven to nine days. In all five cases of None of these patients complained of any pain in complete denervation, who showed the most severe the appropriate ear apart from pain at the site of facial palsy, the delay in onset of the facial palsy impact before the onset of facial palsy. This was was between two and six days. The cases of partial looked for especially in cases where facial palsy denervation had a wider scatter in the day of onset J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.40.4.342 on 1 April 1977.
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