Post-Traumatic Craniotomy with Facial Nerve Palsy in Pediatric Patient
Case at a Glance
A 12-year-old female presented with unilateral facial paralysis following craniotomy for evacuation of epidural hematoma after traumatic skull fracture.
Patient's Story
A 12-year-old girl sustained blunt head trauma resulting in a right-sided skull fracture. Following the injury, imaging revealed an epidural hematoma requiring urgent surgical intervention. The patient underwent craniotomy with hematoma evacuation. The surgical approach was performed in the right temporal region, superior to the ear. Concurrently, the patient suffered a tympanic membrane rupture on the ipsilateral side. Post-operatively, the patient developed right-sided facial weakness affecting voluntary facial movements.
Initial Assessment
Post-operative examination revealed right-sided facial nerve dysfunction manifesting as incomplete eyelid closure during voluntary blinking and asymmetric facial expression during smiling and laughing. The right side of the face demonstrated reduced muscle activation compared to the contralateral side. Associated finding included right tympanic membrane perforation. The patient was managed with acetaminophen for pain control with no other medications.
The Diagnostic Journey
Clinical examination confirmed lower motor neuron facial nerve palsy, likely secondary to surgical trauma during the craniotomy procedure. The proximity of the surgical site to the facial nerve's temporal branch suggested iatrogenic nerve injury during the evacuation of the epidural hematoma.
Final Diagnosis
Right-sided peripheral facial nerve palsy (House-Brackmann Grade III-IV) secondary to surgical trauma during craniotomy for epidural hematoma evacuation, with concurrent traumatic tympanic membrane perforation.
Treatment Plan
Conservative management with facial nerve function monitoring. Patient education regarding eye protection due to incomplete eyelid closure. Regular ophthalmologic follow-up to prevent corneal complications. Physical therapy consultation for facial exercises to potentially enhance nerve recovery. Serial neurological examinations to assess for improvement in facial nerve function.
Outcome and Follow-up
Facial nerve injury following temporal craniotomy is a recognized complication, particularly when surgical access is near the nerve pathway. Recovery potential varies significantly, with some patients experiencing partial to complete recovery over months to years, while others may have permanent deficits. The degree of recovery depends on the extent of nerve damage during surgery. Continued monitoring and supportive care are essential for optimal outcomes.