Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2016) 17, 23–25

H O S T E D BY
Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences
www.ejentas.com

CASE REPORT

Head injury with sudden onset bilateral facial

palsy – Can happen without temporal bone fractures
and brain injury!
Santosh Kumar Swain a,*, Ishwar Chandra Behera b, Mahesh Chandra Sahu c

a
Department of ENT, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar
751003, Odisha, India
b
Department of Neuro Critical Care, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar,
Bhubaneswar 751003, Odisha, India
c
Central Research Laboratory, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar,
Bhubaneswar 751003, Odisha, India

Received 4 September 2015; accepted 24 November 2015

KEYWORDS Abstract Bilateral sudden facial nerve palsy is an extremely rare clinical entity and in most
Facial palsy; instances is idiopathic. Post traumatic sudden onset bilateral facial palsy is even rarer and unique
Head injury; which makes a challenging situation for understanding the etiopathology and patient management.
Temporal bone fractures We report a case of a 22 year old boy who presented with sudden onset bilateral facial palsy after
mild head injury where the radiological findings of the brain and temporal bone are normal. He was
managed by administrating steroids and he was symptom free by 2 months. This case is unique to
our knowledge, post traumatic bilateral facial palsy with normal radiological findings are rarely
reported in medical literature.
Ó 2015 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
All rights reserved.

1. Introduction unilateral facial paralysis, accounting for approximately 70%

The incidence of unilateral facial nerve palsy is around
20–25 per 100,000 population.1 The etiology is found only in
20% of unilateral facial palsies with majority of the cases being
attributed to idiopathic or Bell’s palsy. Bell’s palsy, also called
as idiopathic facial paralysis, is the most common cause of
* Corresponding author. Cell: +91 9556524887.
E-mail address: santoshvoltaire@yahoo.co.in (S.K. Swain).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2015.11.002
2090-0740 Ó 2015 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved.
of these cases. Bilateral facial nerve paralysis is exceedingly
rare, representing less than 2% of all the facial palsy cases,
and has an incidence of 1 per 5,000,000 population.2,3 Most
of these patients have serious underlying medical conditions
and need to be admitted for proper evaluation of the underly-
ing cause and further management. Bell’s palsy accounts for
only 23% of bilateral facial paralysis.2 Trauma accounts for
a very less percentage of bilateral facial palsy and is associated
with skull base and temporal bone fractures.4 This case is
unique to the best of our knowledge as traumatic bilateral
24 S.K. Swain et al.

facial palsy with normal radiological imaging has been rarely

reported previously.

2. Case report

A 22 year old boy presented to the outpatient department of

Otorhinolaryngology with complaints of being unable to close
both eyes (Fig. 1), blow the cheek and stasis of food in the ves-
tibule of the mouth since 1 week. He had suffered a road traffic
accident 1 week back with lacerated injury to the forehead and
face. He had no neurological deficits and no ENT complaints
at time of injury except bilateral facial weakness with lacerated
injuries over the face.
Examinations revealed lower motor neuron lesions of bilat-
eral facial nerve palsy. Examination of the other cranial nerves
showed normal findings. On otoscopic examination, both sides
the external auditory canal and tympanic membranes were
normal. Pure tone audiometry (PTA) showed bilateral normal
hearing sensitivity. Power in all limbs was normal, deep tendon
reflexes were present and his sensory examination was unre-
markable. There were no cerebellar signs. An urgent computed
tomography (CT) scan of the temporal bone (Fig. 2) and the
Figure 2 CT scan of the temporal bone showing no evidence of
brain (Fig. 3) were done which did not reveal any obvious
fracture.
abnormality. His hematological and biochemical blood tests,
including liver function tests and thyroid hormone levels were
normal. There was no progression of his symptoms during a
few days of hospitalization. He took oral steroids in tapering

Figure 3 CT scan of the brain showing no evidence of injury.

doses and was advised for eye care and facial exercises, then
he become symptom free by 2 months.

3. Discussion

Bilateral traumatic facial paralysis is an extremely rare clinical

Figure 1 Patient is unable to close the both eyes and indicating
bilateral facial palsy.
condition. Bilateral simultaneous facial paralysis is described
as facial paralysis involving both sides of the face occurring
within 4 weeks of each other, and is found in 0.3–2 per cent
of facial paralysis.5 Unlike the unilateral presentation, it is sel-
dom secondary to Bell’s palsy. The majority of patients with
non-traumatic bilateral facial palsy have Gullain–Barre
Head injury with sudden onset bilateral facial palsy
syndrome, multiple idiopathic cranial neuropathies, Lyme dis-
ease, sarcoidosis, meningitis, brain stem encephalitis, benign
intracranial hypertension, leukemia, Melkersson Rosenthal
syndrome, diabetes mellitus, HIV infection, syphilis, infectious
mononucleosis, malformation as Mobius syndrome, vasculitis
or bilateral neurofibromatosis.6
The facial nerve is the most commonly injury in closed head
trauma. Trauma is the second most common identifiable cause
of facial nerve palsy. Immediate facial nerve palsy following
head injury is easily explained but bilateral facial nerve palsy
with normal radiological imaging of brain and temporal bone
is not clear.
Anatomically the facial nerve occupies 30–50% of the
cross-sectional area of the fallopian canal with the reminder
being occupied by blood vessels with loosely arranged connec-
tive tissue. Even with the absence of temporal bone fracture
and brain injury, the cause of facial palsy may be due to bleed-
ing into the facial canal. Increasing the size of hematoma in the
limited expanding bony canal compresses the facial nerve and
ultimately causes ischemic damage to the facial nerve.7
Mild head injury causing bilateral facial nerve palsy is an
uncommon incidence8 as happens in our case.
Longitudinal fractures of the temporal bone account for
90% of all fractures and cause facial nerve palsy in 10–25%
of the cases9 whereas transverse fractures of the temporal bone
account for 10% and cause facial nerve palsy in 30–50% of
cases.10 In both types of cases facial nerve injury occurs in
the peri-geniculate region. Bilateral traumatic facial nerve
paralysis usually occurs in longitudinal temporal bone frac-
tures across the skull base. The mechanics of fracture disloca-
tion of petrous temporal bone is complicated and involves
backward displacement of the petrous apex, coronal splitting
of the body of sphenoid leading to mirror image fracture in
the opposite temporal bone. Bilateral facial nerve injury is
not usually associated with transverse fracture of the temporal
bone.11
Assessment of the facial nerve should be complemented by
testing hearing, the acoustic reflex, taste and Schirmer’s tear
test. Laboratory tests have little value in contest of trauma.
Plain skull X-rays provide little information where there is sus-
picion of temporal bone fracture. High resolution CT scan is
the investigation of choice as it gives accurate localization of
fracture sites and post-traumatic state of the middle ear and
facial nerve canal.12 MRI of the brain is not routinely done
in facial nerve palsy. However, MRI with gadolinium contrast
can be used for predicting the site of facial nerve injury. Elec-
tromyography should be a part of investigations in facial nerve
palsy and is a reliable prognostic indicator.13 Nevertheless it is
still an important test but is useful only several days after
trauma to the nerve.
The management of traumatic facial palsy is still controver-
sial and needs close observation. Steroids are usually adminis-
tered to the patients with either traumatic or infectious facial
palsy. Steroids have been used to decrease edema, swelling
and scar formation.14 Our patient was managed by adminis-
trating steroids and he was symptom free by 2 months. As
25
patients are unable to close their eyes, eye care is needed to
prevent keratitis by application of artificial tears. Surgery is
only needed when there is penetrating injury to the temporal
bone or transaction of the facial nerve. Surgical decompression
of the facial nerve after blunt trauma is controversial as most
of the cases resolve spontaneously.15
4. Conclusion
Bilateral facial nerve palsy is an extremely rare clinical entity.
Traumatic bilateral facial nerve palsy with normal radiological
imaging is rarely documented in medical literature. Thorough
clinical history and physical examination, high resolution CT
scan and electrodiagnostic tests can help to make the diagnosis
of bilateral facial nerve palsy and early detection, evaluation
and intervention may be important for optimal functional
recovery. Most patients of post-traumatic facial nerve palsy
recover with conservative treatment .Facial nerve decompres-
sion and reanimation are, in fact, rarely needed.
References
1. Price T. Bilateral simultaneous facial palsy. J Laryngol Otol.
2002;116:46–48.
2. Keane JR. Bilateral seventh nerve palsy: analysis of 43 cases and
review of the literature. Neurology. 1994;44(7):1198–1202.
3. Teller DC, Murphy TP. Bilateral facial paralysis: a case presenta-
tion and literature review. J Otolaryngol. 1992;21:44–47.
4. Guerrissi JO. Facial nerve paralysis after intratemporal and
extratemporal blunt trauma. J Craniofac Surg. 1997;5:431–437.
5. Teller DC, Murphy TP. Bilateral facial paralysis: a case presenta-
tion and literature review. J Otolaryngol. 1992;21:44–47.
6. Pothiawala S, Lateef F. Bilateral facial nerve palsy: a diagnostic
dilemma. Case Rep Emerg Med. 2012;3:1–3.
7. Vijay SI, Vijay KDJ, Rao K, Sharma V, Chopra S. Delayed onset
post-traumatic bilateral facial nerve paralysis – a rare case report.
Indian J Neurotrauma. 2012;9:143–146.
8. Ahmad FU, Suri A, Garg A, Mahapatra AK, Mehata VS. Post
traumatic bilateral facial palsy causing severe psychosocial impair-
ment. Pan Arab J Neurosurg. 2009;13:125–127.
9. Li J, Goldberg G, Munin MC, Wagner A, Zafonate R. Post
traumatic bilateral facial palsy: a case report and literature review.
Brain Inj. 2004;18:315–320.
10. Harker A, McCabe F. Temporal bone fracture and facial nerve
injury. Otolaryngol Clin North Am. 1991;24:425–431.
11. De Villiers JC. Fracture-dislocation of the petrous temporal bone.
J Neurosurg Psychiatr. 1971;34:104–109.
12. Schbiger O, Valavanis A, Stuckman G, et al. Temporal bone
fractures and their complications. Examination with high resolu-
tion CT. Neuroradiology. 1986;28:93–99.
13. Kalsi P, Martinez JC. Bilateral facial palsy following blunt
trauma. Injury Extra. 2007;38:94–96.
14. Hwang JY, Jwa CS, Kim KH, Kang JK. Post-traumatic bilateral
facial palsy – A case report. J Kor Neurotraumatol Soc. 2006;2
(2):136–139.
15. Ulug T, Ulubil A. Bilateral traumatic facial paralysis associated
with unilateral abducens palsy: a case report. J Laryngol Otol.
2005;119(2):144–148.