Facial nerve paralysis following transtympanic penetrating middle ear trauma.

2. Lasak JM et al. Middle ear injury through the external auditory canal: a review of 44 cases. 3. Snelling JD et al. Unusual middle-ear mischief: trans-tympanic trauma from a hair grip resulting in ossicular, facial nerve and oval window disruption. 4. Neuenschwander et al. Penetrating middle ear trauma: a report of 2 cases. This case represents a rarely reported sequela of penetrating middle ear injury— facial paralysis. We postulate that either direct trauma from the earring itself or displacement of the incus into the tympanic segment of the facial nerve 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)  Blast injuries Typical findings are:  Tympanic membrane perforation  Hearing loss and tinnitus  Vertigo  Otorrhea  Ossicular injury  Perilymph fistula  Cholesteatoma (delayed)  Facial nerve injury Perforating trauma to the posterosuperior quadrant of the tympanic membrane specifically places a number of middle ear structures at risk because of their anatomical alignment. These include all three ossicles, the facial nerve and the oval window. Thus, 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. We propose that management should be similar to that for facial paralysis secondary to temporal bone fractures from external forces. A 26-year old-woman without significant past medical history presented to our outpatient department with unilateral complete facial nerve paralysis and severe hearing loss. One day prior to presentation the patient had experienced a transtympanic penetrating middle ear trauma when she had fallen and a long earring was pushed into the left external auditory canal. Approximately 6 hours after the trauma she 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. …