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Facial nerve paralysis following transtympanic penetrating middle ear trauma.

Penetrating injuries violating the tympanic membrane and resulting in middle ear trauma may cause minor temporary symptoms or significant debilitation. Knowledge of the anatomy of the middle and inner ear is vital to proper diagnosis and appropriate treatment of these injuries. Here we report a case of facial nerve paralysis following transtympanic penetrating middle ear trauma, a situation that has been rarely reported in the literature.

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A 26-year-old woman presented to our outpatient department with unilateral complete facial nerve paralysis and severe hearing loss. One day earlier, she had experienced transtympanic penetrating middle ear trauma when she had fallen and a long earring had pushed into her left external auditory canal. Approximately 6 hours after the trauma, she had noticed the onset of facial nerve weakness, subsequently progressing to complete paralysis.

Physical examination revealed a 40% superior tympanic membrane perforation, a posterior canal laceration, and a House-Brackmann grade VI paralysis. Initial tuning fork examination was consistent with a conductive hearing loss. Audiometry was performed, confirming a 60-dB left-sided conductive hearing loss. High-resolution computed tomography (CT) of the temporal bones showed significant ossicular displacement; no evidence of a fracture or penetrating bony spicule involving the tympanic segment of the facial nerve was found (figure).

High-dose oral steroid therapy was initiated with a dose of 1 mg/kg/day of oral prednisone. Four days after the initial trauma, the patient showed no improvement in facial motion, but 8 days later, her facial nerve function had improved to a House-Brackmann grade IV. She did not return for further follow-up visits.

This case represents a rarely reported sequela of penetrating middle ear injury--facial paralysis. (1-3) Direct trauma from the earring itself or displacement of the incus into the tympanic segment of the facial nerve likely led to the development of edema and subsequent delayed-onset paralysis. No specific management guidelines are available for this type of injury, so we followed a typical strategy for facial paralysis secondary to temporal bone fractures. Because the paralysis was delayed in onset and the CT showed no gross abnormalities of the nerve, we proceeded with conservative management, including high-dose steroid therapy.

Common causes of penetrating middle ear trauma include foreign bodies, thermal injuries (e.g., slag burns), and blast injuries? Complications to consider are tympanic membrane perforations, hearing loss and tinnitus, vertigo, otorrhea, ossicular injury, perilymph fistula, delayed cholesteatoma formation, and facial nerve injury. Perforating trauma to the posterosuperior quadrant of the tympanic membrane specifically places a number of middle ear structures at risk--including all three ossicles, the facial nerve, and the oval window--because of their anatomic alignment. Dislocation at the malleoincudal articulation, incudostapedial joint, or both is possible and commonly occurs. The concomitant facial nerve injury described here is a rare event but should be kept in mind as a possible finding and treated aggressively. Management should be similar to that for facial paralysis secondary to temporal bone fractures from external forces.

References

(1.) Lasak JM, Van Ess M, Kryzer TC, Cummings RJ. Middle ear injury through the external auditory canal: A review of 44 cases. Ear Nose Throat J 2006;85(11):722, 724-8.

(2.) Snelling JD, Bennett A, Wilson P, Wickstead M. Unusual middle-ear mischief: Trans-tympanic trauma from a hair grip resulting in ossicular, facial nerve and oval window disruption. J Laryngol Otol 2006;120(9):793-5.

(3.) Neuenschwander MC, Deutsch ES, Cornetta A, Willcox TO. Penetrating middle ear trauma: A report of 2 cases. Ear Nose Throat J 2005;84(1):32-5.

From the Department of Otolaryngology--Head and Neck Surgery, Mount Sinai School of Medicine, New York City.
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Title Annotation:OTOSCOPIC CLINIC
Author:Iloreta, Alfred Marc; Malkin, Benjamin D.
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Nov 1, 2011
Words:595
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