Working Diagnosis:
Unilateral ptosis likely secondary to incomplete facial nerve palsy in the setting of concussion

Treatment:
Upon follow up to our clinic two weeks later, the ptosis was resolving. The patient was symptom-free, and the ptosis was completely resolved at follow up one month after the injury. If we did not see improvement of his ptosis within a month of injury, the next step would be to obtain an electromyography (EMG) of cranial nerve seven.

Outcome:
Cranial nerve seven innervates the frontalis muscle, which works to lift the eyebrows. Cranial nerve seven palsy can lead to eyelid ptosis secondary to eyebrow ptosis. It can occur after traumatic head injury, but it is most often associated with temporal bone fracture; the nerve is particularly vulnerable as it courses through the temporal bone. There was no concern for skull fracture in our patient. In the setting of acute-onset ptosis with the concern for a cranial nerve palsy, brain imaging should be obtained to rule out an intracranial mass. To our knowledge, this is the first documented case of unilateral ptosis and suspected incomplete cranial nerve seven palsy following concussion.

Editor's Comments:
This case highlights an interesting and rare complications following head trauma. All neurologic findings in a patient with head injury require evaluation. In the case presented here the patient had a isolated lesion of the temporal branch of the facial nerve. In a literature review I did find to other reported cased with minor head trauma, but none with sports.
In this case, return to play decision would have to be made off of resolution of concussive symptoms and with resolution of ptosis.

References:
1.) Finsterer, J. Ptosis: causes, presentation, and management. Aesthetic Plastic Surgery 2003; 27:193-204.
2.) Kanagalingam, S., Miller, N. Horner syndrome: clinical perspectives. Eye Brain 2015; 7:35-46.
3.) Mavrikakis, I. Facial nerve palsy: anatomy, etiology, evaluation and management. Orbit 2008; 27:466-474.
4.) Odebode, T., Ologe, F. Facial nerve palsy after head injury: case incidence, causes, clinical profile and outcome. J Trauma and Acute Care Surg 2006; 61:388-91.
5.) Dhaliwal, A., et al. Third, fourth, and sixth cranial nerve palsies following closed head injury. J Neuro-Ophtho 2006; 26:4-10.
6.) Valls-Sole, J. Electrodiagnostic studies of the facial nerve in peripheral facial palsy and hemifacial spasm. Muscle and Nerve 2007; 36:14-20.

Return To The Case Studies List.