Fracture of Skull Base With Delayed Multiple Cranial Nerve Palsies Altan Yildirim, MD,* Mustafa Gurelik, MD, y Cesur Gumus, MD,z and Tanfer Kunt* Abstract: This report describes a pediatric case of delayed glos- sopharyngeal nerve, vagus nerve, and facial nerve palsies after a head injury. Computed tomography scan of the skull base revealed the fracture of the petrous part of the temporal bone, and the fracture involved the tip of petrous pyramid, in front of the jugular foramen. The anatomical features, mechanisms, diagnosis, and treatment are discussed. Key Words: skull base fractures, delayed multiple nerve palsies S icard 1 has first reported a ‘‘pharyngeal scapular palato- glossal laryngeal hemiplegia’’ after bullet trauma to the mastoid area. Collet 2 has reported a similar case and described ‘‘jugular foramen junction syndrome’’ or ‘‘jugular foramen syndrome,’’ depending on the involvement of hypoglossal nerve. Due to the strategic anatomical location of the occipital condyles, their traumatic lesions may be accompanied by immediate or delayed paralysis of an individual nerve or several lower cranial nerve palsies. 3,4 The phenomenon of skull base fractures involving the lower cranial nerves is relatively rare. 5 CASE This 8-year-old boy has fallen down from the roof of his home and had a closed head injury. He was admitted comatose with a Glasgow Coma Scale score of 9 to neurosurgery clinic. There was a hematoma of his scalp on the left temporoparietal location. Moreover, there was otorrhea with hemorrhage in the left ear. Computed tomography (CT) scan showed wiped-off gyri, subar- achnoid hemorrhage, pneumoencephaly, and severe brain edema (Fig. 1). The patient was admitted to intensive care unit for artificial ventilation under sedation with benzodiazepines and narcotics. He gained consciousness rapidly and was extubated on the second day. He had lumbar puncture for several days, and his otorrhea has disappeared. There was no neurological deficit when he was discharged. Two weeks later, he had problems in swallowing and left eye closure and dysphonia. Otolaryngological examination has revealed ipsilateral paralysis of left vocal cord and soft plate and facial nerve paralysis. Moderate left-sided neurosensorial hearing loss (45dBHL) was diagnosed at audiological examination. Facial paralysis of the patient was at grade IV of Hause-Brackman facial nerve grading system. CT scan of the skull base revealed the fracture of the petrous part of the temporal bone, and the fracture involved the tip of petrous pyramid, in front of the jugular foramen (Fig. 2). He was referred to neurosurgery clinic, treated by cervical collar, and fed via nasogastric tube for 2 weeks and also given 0.5 mg/kg methylprednisolone for 5 days with a decreasing dos- age of 0.1 mg/kg with 3-day intervals. One month later, glos- sopharyngeal and vagus nerve palsies disappeared, and facial paralysis of the patient was at grade II of Hause-Brackman facial FIGURE 1. CT scan showed wiped-off gyri, subarachnoid hemorrhage, pneumoencephaly, and severe brain edema. 440 Pediatric Emergency Care  Volume 21, Number 7, July 2005 Illustrative Case *Otolaryngology and Head Neck Surgery Department, yNeurosurgery Department and zRadiology Department, Cumhuriyet University Medical Faculty, Sivas, Turkey. Address correspondence and reprint requests to Altan Yildirim, MD, Cumhuriyet Universitesi Kulak-Burun-Bogaz Klinigi, TR-58140 Sivas, Turkey. E-mail: altan11@hotmail.com. Copyright n 2005 by Lippincott Williams & Wilkins ISSN: 0749-5161/05/2107-0440 Copyr ight © Lippincott Williams & Wilkins. Unauthor iz ed reproduction of this article is prohibited.