The diabetic oculomotor nerve palsy may affect isolated superior or inferior division of the oculomotor nerve, but diplopia usually exists. The reason for delaying the surgery until the patient is at least 45 years of age is the necessity of delay for the frontonasal and upper face to complete their complex growth. In a recent population-based cohort study by Fang and colleagues The site is secure. Associated Symptoms(Pain and Other Systemic Complaints). Careers, Unable to load your collection due to an error. [Ptosis in the differential diagnosis of neurologic diseases] Myasthenia Gravis - National Institute of Neurological Disorders and Stroke Regarding this, to the best of our knowledge, there was no case reported in South Korea where facial palsy preceded trismus, but there were five cases where facial palsy occurred prior to trismus in other countries. Neuro-ophthalmologic and Cranial Nerve Disorders. Most patients develop ptosis due to this disease in their adulthood. Goodwin J, Lee AG, Ing EB, Al Othman BAM. Neuroophthalmology. [6] In this study, the most common causes of acquired third nerve palsy were presumed microvascular injury (42%), trauma (12%), compression (from neoplastic lesions) (11%), post-operative neurosurgical cases (10%), and aneurysmal compression (6%). To identify other possible causal diseases or pathological findings, necessary tests such as blood test, urine test, cerebrospinal fluid (CSF) examination, chest radiography, brain computed tomography, and brain magnetic resonance imaging were performed but revealed no abnormal findings. Localizing brainstem findings such as a third cranial nerve palsy and contralateral weakness (Weber syndrome) can help localize a midbrain lesion such as stroke, whereas multiple cranial nerve palsies that are slowly progressive can implicate a chronic compressive lesion (aneurysm, meningioma) of the cavernous sinus. Acquired Oculomotor Nerve Palsy. The affected eye may deviate slightly out and down in straight-ahead gaze; adduction is slow and may not proceed past the midline. 135 (1):23-28. Ptosis may be the presenting sign or symptom of serious neurologic disease. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTE5ODQ2Mi1vdmVydmlldw==. How is fourth cranial nerve palsy diagnosed in the setting of third cranial nerve palsy (oculomotor cranial nerve palsy)?. Myasthenia gravis is a chronic autoimmune, neuromuscular disease that causes weakness in the skeletal muscles (the muscles that connect to your bones and contract to allow body movement in the arms and legs, and allow for breathing). There are several types of ptosis, characterized into two broad categories: congenital ptosis, which is present at birth, and acquired ptosis, which is when the condition develops later in life. C. Surgical third nerve palsy is characterized by a sudden onset of unilateral ptosis and an enlarged or sluggish pupil to the light. Cranial nerves III, IV, VI, VII, and XII may be affected, but the facial nerve is most frequently implicated. Blink reflex study, which was recorded on the orbicularis oculi muscle by stimulating the supraorbital nerve, showed no abnormal findings. Uncal herniation | Radiology Reference Article | Radiopaedia.org Third Nerve Palsy (Oculomotor Nerve Palsy) - Medscape What are the advantages and disadvantages? [QxMD MEDLINE Link]. Binocular diplopia reflects ocular misalignment whereas monocular diplopia implicates an anterior segment issue, or retinal abnormality. Sagging upper eyelids can partially block the field of view. [QxMD MEDLINE Link]. Horner's syndrome (also called oculosympathetic paresis, or Horner syndrome) comprises a constellation of clinical signs including the classic triad of ptosis, miosis, and anhidrosis. Radiopaedia.org. Tetanus: pathophysiology, management, and prophylaxis. P tosis, formally known as blepharoptosis, is a common finding characterized by upper eyelid drooping in primary gaze. Here, it is vulnerable to compressive effects from vascular lesions, such as aneurysms(Figure 4). This consists of ipsilateral VIth nerve palsy and Vth nerve distribution pain and earache/otorrhea. [QxMD MEDLINE Link]. Galtrey CM, Schon F, Nitkunan A. Microvascular Non-Arteritic Ocular Motor Nerve Palsies-What We Know and How Should We Treat?. Types of Ptosis | NYU Langone Health Ptosis (eyelid) - Wikipedia [22], According to ophthalmology studies done on ptosis patients, occurrence rates are as follows. [QxMD MEDLINE Link]. ", Learn how and when to remove this template message, "Ptosis Of The Eyelid: Symptoms, Causes, Treatments", "Ptosis, convergence disorder and heroin", "Lyrica (Pregabalin) Reports of Side Effects & Adverse Reactions", "Traumatic Ptosis: Evaluation of Etiology, Management, and Prognosis", "The emerging syndrome of envenoming by the New Guinea small-eyed snake, "Management of Snake bites in South East Asia Part 2", "Ptosis: Diagnostic Tips & Surgical Options", "What is Frontalis Sling? Can J Neurol Sci. J Accid Emerg Med. Age; eye muscles weaken as they age, increasing the chance of the eyelids drooping. Ptosis is a condition where the upper eyelid droops. Such damage could be a sign of an underlying disease such as diabetes mellitus, a brain tumor, a pancoast tumor (apex of the lung) and diseases that cause weakness in muscles or nerve damage, such as myasthenia gravis or oculopharyngeal muscular dystrophy. Accordingly, they should undergo appropriate evaluation and treatment of their third cranial nerve palsy in a manner that is tailored to their needs. Etienne Benard-Seguin, MD Chief Resident Physician, Department of Ophthalmology, Cumming School of Medicine, University of Calgary, CanadaDisclosure: Nothing to disclose. CSF cell count with differential, glucose, protein, cytopathology, gram stain, viral cultures, fungal cultures, and opening pressure as indicated. Finally, patients should be provided information that facilitates a good understanding regarding the implications of their diagnosis and prognosis for recovery. The following day, there was progression of symptoms to generalized tetanus, such as dyspnea and generalized rigidity. [15] The levator function measures the distance the eyelid travels, starting with the downgaze movement to the upgaze without moving the frontalis muscle. Smith AT, Drew SJ. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate. The Whitnall sling procedure is able to provide a better cosmetic result because the procedure is able to keep the Whitnall's ligament intact. Arch Ophthalmol. Progressive worsening of third cranial nerve palsies may be seen with compressive lesions. . Then the surgeon will suture the Whitnall's ligament connecting it to the superior tarsal edge. Among them, the seventh cranial nerve is most commonly involved, while other cranial nerve palsies are reported to be rare.1,4 In about two-thirds of the patients, tetanus develops into generalized form with mortality of 15-30%.1, In this case, the patient was first diagnosed with palsy of the seventh cranial nerve upon her hospitalization, but was later diagnosed with cephalic tetanus as trismus occurred. Ipsilateral ptosis is localizing for a third cranial nerve palsy. 2019:9185603. After connatal ptosis with or without involvement of other bulbar muscles the different types of muscular dystrophies are Available at https://eyewiki.aao.org/Oculomotor_Synkinesis#cite_note-:0-4. The surgeon will begin with an incision on the eyelid. [2] We report a case admitted the emergency clinic with sudden ptosis in . Babies may also exhibit ptosis at birth as the result of abnormal development of the while the child is in the mother's womb. "Ptosis" means drooping. o [teenager OR adolescent ], , MDCM, New York Presbyterian Hospital-Cornell Medical Center, (See also Overview of Neuro-ophthalmologic and Cranial Nerve Disorders Overview of Neuro-ophthalmologic and Cranial Nerve Disorders Dysfunction of certain cranial nerves may affect the eye, pupil, optic nerve, or extraocular muscles and their nerves; thus, they can be considered cranial nerve disorders, neuro-ophthalmologic read more . 1 The most common cause of ptosis in the older population is aponeurotic due to levator dehiscence. [2] Isolated ONP associated with aneurysm or compressive lesions is characterized by sudden onset, pain, and pupilla involvement. An official website of the United States government. However, tetanus immunoglobulin was not administered because it was considered that it was too late to neutralize the toxin. 83.10). History taking showed that ptosis occurred at nine days after the injury and left facial palsy (Fig. Five main types of acquired ptosis can develop throughout a lifetime. Illustration of common causes of an oculomotor nerve palsy. nerve separates into superior division and inferior division, with the superior division innervating the superior rectus and levator palpebrae superioris. The clinical signs, management, and prognosis were analyzed. government site. [QxMD MEDLINE Link]. Burgess JA, Wambaugh GW, Koczarski MJ. [QxMD MEDLINE Link]. Abrupt onset cranial third nerve palsies suggest a vascular etiology (pituitary apoplexy, subarachnoid hemorrhage) whereas compressive lesions may cause more insidious onset of deficits. Post-traumatic, post-infectious, post-inflammatory, and ischemic oculomotor palsies may spontaneously recover to a variable degree. o [ pediatric abdominal pain ] After ice application, improvement of ptosis suggests a disorder of the neuromuscular junction as a possible mimic of a third cranial nerve palsy. In this case, the possibility of Guillain-Barre syndrome was excluded because the patient had no weakness of limbs and no particular findings on CSF examination. This condition is sometimes called "lazy eye," but that term normally refers to the condition amblyopia. In the case of a neuromuscular junction mimicking a third cranial nerve palsy, the diplopia may be truly intermittent. As a library, NLM provides access to scientific literature. Murchison AP, Gilbert ME, Savino PJ. The remaining cranial nerves were intact, and there was no evidence of sensory or motor weakness. Ptosis(or blepharoptosis) is a drooping or falling of the upper eyelid. A weakening or malfunctioning of the levator muscle, which is responsible for lifting the eyelid, causes this condition. Children receive treatment for ptosis through Hassenfeld Childrens Hospitalat NYU Langone. This results in a lazy eye, or underdeveloped vision in that eye. Upward gaze is impaired. If the ptosis is not related to major health issues (such as cancerous tumors or traumatic injuries), the condition will not shorten the patient's life expectancy. Department of Rehabilitation Medicine, College of Medicine, Dankook University, Cheonan 330-715, Korea. In this case, imaging tests such as CTs or MRIs should be considered. We can help you find a doctor. Park DM. Until now, there has been no case where ptosis was accompanied, though such cases were reported in foreign countries. In this condition, the levator muscle of the eyelid becomes overstretched, usually due to aging. Diplopia is typically worse in the gaze direction of weakest muscle action. 2000 Sep. 41 (9):458-9. Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, FRCSC Professor, Department of Ophthalmology and Vision Sciences, Sunnybrook Hospital, University of Toronto Faculty of Medicine; Incoming Chair of Ophthalmology, University of Alberta Faculty of Medicine and Dentistry, Canada However, it may be associated with various other conditions, such as immunological, degenerative or hereditary disorders as well as tumors or infections.[6]. Patients should be informed regarding potentially life-threatening causes of an acquired third cranial nerve palsy, appropriately weighted to the context of their case. This can occur because of senescence, dehiscence or disinsertion of the levator aponeurosis. Orbital signs such as proptosis and arterialized conjunctival vessels, might suggest an orbital process mimicking a third nerve palsy due to muscle restriction, including Grave's Disease, orbital inflammation, orbital infiltration, or a carotid cavernous sinus fistula (CCF). Ptosis Correction - PubMed 2018 Jan. 38 (1):1-211. Badakere A, Patil-Chhablani P. Orbital Apex Syndrome: A Review. This review summarizes those neurological diseases which are accompanied by a drooping of the upper lid, due to weakness of the m. levator palpebrae or m. tarsalis respectively. Orbital ultrasound can detect arterialized flow through the superior ophthalmic vein, and help localize cases of CCFs. Different trauma can cause and induce many different mechanisms. The hallmark of myasthenia gravis is muscle weakness that worsens after periods of activity and improves after . [4], The overall prognosis of any oculomotor palsy depends on the etiology. Superior Orbital Fissure vs Cavernous Sinus vs Orbital Apex Lesions. 2021 Oct 31; Accessed: December 31, 2021. Patients with a prior history of strabismus with or without surgery might be interpreted to have an acquired third nerve palsy if they are symptomatic for loss of fusional control. The pupil may be normal or dilated; its response to direct and to consensual light may be sluggish or absent (efferent defect). Cephalic tetanus accompanied with at least one cranial nerve palsy, in particular, is very rare, accounting for only 0.9-3% of total tetanus cases.1 Thus, not many clinicians are familiar with it. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. Available at https://eyewiki.aao.org/Cavernous_Sinus_Syndrome#cite_note-:1-2. Myasthenia gravis is a common neurogenic ptosis that could also be classified as neuromuscular ptosis because the site of pathology is at the neuromuscular junction. The patient has been in good condition without complications or relapse till now. Intermittent diplopia may be gaze directional or reflect a breakdown of binocular fusional control. Moran CORE | Ptosis - University of Utah CT or MRI is required. Even if the immunoglobulin was administered, we believe that the symptoms of generalized tetanus could not have been controlled. 63 (5):771-6. Tel: +82-41-550-6640, Fax: +82-41-551-7062. Follow us on Facebook. A Case of Cephalic Tetanus with Unilateral Ptosis and Facial Palsy Table 1: Details from the Clinical History that Help Localize a Third Cranial Nerve Palsy, Table 2:Examination Findings that Can Help Localize a Third Cranial Nerve Palsy, Table 4:Investigations to Consider in Evaluating Patients with Third Cranial Nerve Palsies. Cavernous sinus disease and orbital mucormycosis require immediate MRI imaging for timely treatment. Ptosis as the only manifestation of diabetic superior : Medicine Treasure Island (FL): 2021 Jan. [Full Text]. Orbital signs such as proptosis and arterialized conjunctival vessels, might suggest an orbital process mimicking a third nerve palsy due to muscle restriction, including Graves Disease, orbital inflammation, orbital infiltration, or a carotid cavernous sinus fistula (CCF). Multiple cranial nerve palsies might indicate lesions of the brainstem, cavernous sinus, skull base, or a more generalized peripheral nerve process such as Miller Fisher Syndrome. Herpes zoster ophthalmicus (HZO) is a viral condition that presents as a painful vesicular rash in the trigeminal nerve dermatome. A drooping eyelid can be one of the first signals of a third-nerve palsy resulting from a cerebral aneurysm that is otherwise asymptomatic, a condition known as oculomotor nerve palsy. StatPearls [Internet]. At fifteen days after the injury, trismus (so severe that she could not open her mouth 5 mm or more) and dysphagia occurred, and on the next day, dyspnea and catochus occurred, symptoms aggravated so badly that endotracheal intubation was performed. It moves to the neuromuscular junction from the wound, thereafter travels up the axon, finally reaching the central nervous system including the anterior horn cell of the spinal cord.1 It also causes over-activation of the motor system by reducing the secretion of -aminobutyric acid and glycine. (A) Wound scar (arrow) on the left forehead. Neuroimaging and acute ocular motor mononeuropathies: a prospective study. Causes of congenital ptosis remain unknown. Neurogenic ptosis occurs when there is a problem with the nerve pathway that controls movement of the eyelid muscles. In myogenic ptosis, the levator muscle is weakened due to a systemic disorder that causes muscle weakness. Exposure to the toxins in some snake venoms, such as that of the black mamba, may also cause this effect. Thus, in this patient's case, we did not administer immunoglobulin considering that it was too late to neutralize the toxin as it had already reached the central nervous system at the time of diagnosis. Bayan Ali Mahmoud Al Othman, MD Fellow in Neuro-Ophthalmology, Houston Methodist HospitalDisclosure: Nothing to disclose. Partial ptosis is due to a dysfunction of the sympathetic pathway leading to paralysis of Muller muscle. [4] Lesions of the cavernous sinus often produce third nerve palsies that are accompanied by one or more other neurologic findings including palsies of the fourth, fifth (first division), and sixth cranial nerves, with or without an associated Horner syndrome. Enter search terms to find related medical topics, multimedia and more. Follow us on Instagram. Available at https://eyewiki.aao.org/Acquired_Oculomotor_Nerve_Palsy. Cranial nerves III, IV, VI, VII, and XII may be affected, but the facial nerve is most frequently implicated. Cell count with differential, hemoglobin AIC, serum sedimentation rate, c-reactive protein, free T3, free T4, TSH, prolactin, FSH, LH, free testosterone, lipid profile, IGF-1, morning cortisol, anti-acetylcholine receptor antibodies, anti-MuSK antibodies, serum lactate, connective tissue screen, genetic testing for mitochondrial disorders and oculopharyngeal muscular dystrophy. INTRODUCTION Blepharoptosis, or ptosis of the eyelid, refers to drooping of the upper eyelid that usually results from a congenital or acquired abnormality of the muscles that elevate the eyelid. Department of Rehabilitation Medicine, College of Medicine, Dankook University, San 16-5, Anseo-dong, Cheonan 330-715, Korea. However, polyphasic motor unit action potentials that represent the recovery of facial muscles were not clearly observed. Websites Privacy Policy. A case of fluctuating ptosis presenting like myasthenia was seen by Netravathi et al. Imaging in Neuro-ophthalmology. We address the early attempts at ptosis surgery, assess the more modern approach by de Blaskovics, followed by the division into "open sky" and "closed" techniques. Courtesy of Tyler Henry, MD, Medical Illustrator (tylerhenrymd.com). This eye position reflects the unopposed actions of depression and abduction of the globe, which are governed by superior oblique (innervated by the fourth cranial nerve) and lateral rectus (innervated by the sixth cranial nerve) muscles, respectively. In this patient's case, ptosis preceded facial palsy and trismus, and was thus the sole symptom at the early phase of the disease. Cranial nerve palsies in tetanus: cephalic tetanus. Lee AG, Kini A, Al Othman B. Oculomotor Synkinesis. The clinical manifestations of third cranial nerve dysfunction reflect its constituent parts. Obstructed vision may necessitate tilting the head backward to speak. Brazis PW, Masdeau JC, Miller J. Localization in Clinical Neurology. Learn more about the Merck Manuals and our commitment to Global Medical Knowledge. Singapore Med J. Ptosis | Practical Neurology Once the levator has been exposed, the surgeon either folds it or cuts it off before suturing it to the tarsal plate. Eyewiki. Copyright 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. A 64-year-old female visited hospital for left ptosis followed by facial palsy after a left forehead abrasion in a car accident. Ptosis may also result from reduced activity of the muscles that elevate the eyelid. If the pupil is affected, it is dilated, and light reflexes are impaired. Traumatic ptosis is caused by an injury to the eyelideither due to an accident or other eye trauma. The ophthalmologist may also measure the degree of the eyelid droop by measuring the marginal reflex distance, which is the distance between the center of the pupil and the edge of the upper lid, as well as the strength and function of the patient's levator muscle. Because the read more, Less commonly, meningitis affecting the brain stem (eg, tuberculosis meningitis), The most common cause of palsies that spare the pupil, particularly partial palsies, is, Ischemia of the 3rd cranial nerve (usually due to diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Philadelphia: Wolters Kluwer Health; 2022. Elsevier Australia. 3rd ed. Exophthalmos or enophthalmos, a history of severe orbital trauma, or an obviously inflamed orbit suggests an intraorbital structural disorder. . This can be caused by nerve damage, underlying medical conditions, or more serious factors like a stroke or neurological disorders. The average age for mechanical ptosis is 49.41 years in females and 43.30 years in males. 1996 Oct. 53 (10):967-71. Overview of ptosis - UpToDate If you need help accessing our website, call 855-698-9991. If a patient has a dilated pupil and a sudden, severe headache (suggesting ruptured aneurysm) or is increasingly unresponsive (suggesting herniation), neuroimaging (CT or, if available, MRI) is done immediately. Cephalic tetanus is defined as a combination of trismus and paralysis of one or more cranial nerves. Opens in a new window. If the surgery is not done carefully, the patient may experience dry eyes because the eye is no longer closing fully. The trusted provider of medical information since 1899, Overview of Neuro-ophthalmologic and Cranial Nerve Disorders, Third Cranial (Oculomotor) Nerve Disorders, Reviewed/Revised Feb 2022 | Modified Sep 2022. The https:// ensures that you are connecting to the These conditions may include chronic progressive external ophthalmoplegia and types of muscular dystrophy. : a comparison of eye care in an accident and emergency department with a dedicated eye casualty. Upon her transfer to our hospital from her local hospital, initial assessment showed that her awareness and vital signs were normal. [QxMD MEDLINE Link]. 2006 May. Available at https://eyewiki.aao.org/Myasthenia_Gravis. Myasthenia Gravis. [18] Although this procedure can be completed through two different approaches, the internal and the external, the external approach allows the surgeons to obtain a better view of the surgical site during the procedure. Acquired ptosis is most commonly caused by aponeurotic ptosis. Use for phrases At the time the article was last revised Patrick J Rock had no recorded disclosures. This condition occurs due to a weakness or disorder of the levator muscle, which controls the upper eyelid . . Through these tests, the ophthalmologist may properly diagnose ptosis and identify its classification, and a determination may be made regarding the course of treatment, which may involve surgery.[11]. In this case, an elderly patient with low immunity got infected with Clostridium tetani via an abrasion. Other causes of ptosis include eyelid neoplasms, neurofibromas or cicatrization after inflammation or surgery. Horner Syndrome - EyeWiki How far we have come: A review of the evolution of posterior - PubMed Weakness of eye closure can be seen with myasthenia gravis and in patients with multiple cranial neuropathies (ie, Miller Fisher Syndrome). Prominent fatigue and variability with respect to ptosis and diplopia often implicate a neuromuscular junction abnormality in lieu of a third cranial nerve palsy. 2019 Oct. 25 (5):1438-1490. https://eyewiki.aao.org/Myasthenia_Gravis. Tamhankar MA, Volpe NJ. These include aponeurotic ptosis, which is the most common type. CNIII, CNIV, CNV1, CNV1, CNV2 (posterior), sympathetic innervation. Ptosis can also occur in a patient with brain tumors due to pressure on the third nerve, also known as the sympathetic nerve, on the brainstem. Gleeson T, Erienne M. Cranial nerve VII palsy as the first sign of cephalic tetanus after an earthquake. If severe enough and left untreated, the drooping eyelid can cause other conditions, such as amblyopia or astigmatism, so it is especially important to treat the disorder in children before it can interfere with vision development. Bilateral ptosis: an atypical presentation of neurocysticercosis Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. The third cranial nerve, alternatively known as the oculomotor nerve, has multiple important functions. Nerve conduction study of the seventh cranial nerve showed normal compound muscle action potential, and needle electromyography of the craniocervical muscles showed no abnormal spontaneous activity. Ocular Motility Because untreated congenital ptosis can have negative effects on your childs vision, experts may suggest surgical treatmentat a young age to prevent any complications. Although the immunoglobulin was not administered at an appropriate timing, antibiotics and sedatives were administered appropriately, and rehabilitation program was appropriately performed, thereby the symptoms improved. 2021 Sep 8; Accessed: December 20 2021. Myasthenia Gravis - EyeWiki A 64-year-old female visited hospital for left ptosis followed by facial palsy after a left forehead abrasion in a car accident. The lid position and pupil size are typically affected by this condition, and the ptosis is generally mild, no more than 2 mm. 2020 Jun 22; Accessed: Dec 19, 2021. Medscape Education, Multifocal Motor Neuropathy: Getting Into Focus With Causes, Symptoms, and Diagnosis, 20021200187-overviewDiseases & Conditions, 20021146903-overviewDiseases & Conditions, Third Nerve Palsy (Oculomotor Nerve Palsy), encoded search term (Third Nerve Palsy (Oculomotor Nerve Palsy)) and Third Nerve Palsy (Oculomotor Nerve Palsy), Trochlear Nerve Palsy (Fourth Nerve Palsy), Abducens Nerve Palsy (Sixth Cranial Nerve Palsy), A 25-Year-Old Woman With a Droopy Eyelid and Double Vision, Cutting-Edge Nasal Tech Could Usher in a New Era of Medicine. Medscape. Acquired Horner syndrome may result after trauma, neoplastic insult or even vascular disease. [24], Current studies have indicated that previous methods, such as occlusion therapy and surgery, are considered the most appropriate for treating this condition. In cephalic tetanus, palsy of the seventh cranial nerve is known to occur at the time of or after the onset of trismus.6 However, in this patient's case, diagnosis with tetanus was delayed because facial palsy occurred before the onset of trismus. 1-A) due to a vehicle accident twelve days before her presentation to our hospital. Fiona Costello, MD, FRCP Associate Professor, Department of Clinical Neurosciences, Neuro-opthalmologist, Clinical Neurologist and Clinical Investigator, Hotchkiss Brain Institute, University of Calgary Faculty of Medicine, Canada Use OR to account for alternate terms Patient concerns: A 56-year-old female was admitted to our hospital for acute onset right upper lid . Follow us on LinkedIn.