Clinical context and objective

Blepharoptosis, or ptosis, following craniofacial trauma, represents a diagnostic and management challenge in oral and maxillofacial surgery. This case report documents the situation of a 27-year-old patient admitted after a road traffic accident, presenting with pain and massive edema of the middle and upper thirds of the face. The initial clinical examination revealed severe facial asymmetry, anisocoria with a fixed left pupil in mid-driasis, as well as total restriction of ocular mobility on the left, all occurring within a context of bilateral temporal bone fractures and frontotemporal lesions confirmed by CT scan, despite a Glasgow score of 15/15.

The specific objective of this presentation is to report the management and favorable evolution of this post-traumatic unilateral ptosis, which achieved complete recovery over a 12-week period. The study tests the hypothesis that close neurological and ophthalmic monitoring, coupled with a precise evaluation of the anatomical components of palpebral elevation, is essential to differentiate acute neurological disorders from purely mechanical impairments related to fractures of the skull base and the facial skeleton.

Management methodology

This case report details the diagnostic management and clinical follow-up of a single patient, a 27-year-old male, admitted to the oral and maxillofacial surgery department following a road traffic accident resulting in severe facial and cranial trauma.

The evaluation protocol was based on the following steps:

• Initial clinical examination: Evaluation of pain, swelling of the upper and middle thirds of the face, as well as facial asymmetry. A rigorous inspection revealed bilateral periorbital ecchymosis, oedema, and subconjunctival haemorrhage.
• Neurological evaluation: Measurement of the state of consciousness via the Glasgow Coma Scale (GCS), establishing a score of 15/15.
• Ophthalmological examination: Analysis of ocular motility (complete restriction on the left, medio-lateral on the right), pupillary reactivity (anisocoria with fixed left pupil in mid-mydriasis and slow right pupil) and visual acuity (normal vision on the right, blurred vision on the left).
• Medical imaging: Performing a computed tomography (CT scan) to identify internal structural lesions.

The diagnosis revealed bilateral temporal bone fractures associated with bilateral fronto-temporal contusions. The clinical progression of the unilateral ptosis and associated deficits was monitored over a total period of 12 weeks until recovery.

Full neurological recovery within 12 weeks

The patient, a 27-year-old male victim of a road traffic accident, initially presented with a severe clinical picture marked by major facial asymmetry, bilateral edema, and subconjunctival hemorrhage. The initial neurological examination showed a Glasgow Coma Scale (GCS) score of 15/15, contrasting with the severity of the local ocular injuries.

CT-scan imaging revealed significant structural lesions: a bilateral temporal bone fracture associated with bilateral fronto-temporal involvement. The initial ophthalmic examination revealed specific focal neurological deficits:

Face to this traumatic ptosis and the associated ophthalmoplegia, the question of prognosis arose. The evolution was marked by a progressive resolution of symptoms without any invasive surgical intervention mentioned for the ptosis itself. Clinical observations confirm a total recovery of palpebral function and ocular motility over a 12-week period.

This observation highlights the recovery capacity of the involved cranial nerves (notably the oculomotor nerve III) following severe craniofacial trauma including fractures of the skull base. The three-month period appears here as the pivot for functional restoration.

Clinical analysis: Ptosis as a post-traumatic sentinel

The case of this 27-year-old patient highlights the importance of a systematic ophthalmic evaluation in the face of complex facial trauma. Although the GCS score remained stable at 15/15, the presence of unilateral blepharoptosis, associated with restriction of ocular movements and bilateral frontotemporal contusions, testifies to the violence of the impact. Clinically, the spontaneous resolution of the ptosis over a 12-week period suggests that a conservative approach can be successful when the anatomical structures responsible for eyelid elevation retain functional recovery potential despite the initial trauma.

Limits and perspective

As this is a single case report, these observations cannot be generalized to all maxillofacial traumas. Nevertheless, the documented association between bilateral temporal bone fractures and the oculomotor disorders observed here illustrates the classic mechanisms of nerve injury by compression or stretching during road traffic accidents. The study does not specify any specific surgical intervention for the ptosis, which limits the analysis of invasive therapeutic options, but validates the three-month window as a temporal benchmark for spontaneous neurological recovery.

Implications for practice

The discovery of anisocoria (left pupil fixed in mydriasis) in the acute phase must alert the practitioner to the severity of the underlying intracranial lesions, beyond the apparent facial asymmetry. For the maxillofacial surgeon, the management of these polytrauma cases requires immediate coordination with neurosurgery and ophthalmology departments. This case demonstrates that in the absence of confirmed nerve section, clinical patience is required: ptosis recovery can be slow but complete, radically changing the aesthetic and functional prognosis for the patient.

In concrete terms, for the practitioner:

• Neurological alert: In the presence of midface trauma (involving the zygomatic arch or the coronoid process), anisocoria and ptosis require an immediate brain CT scan to rule out a temporal bone fracture.
• Surgical temporization: Traumatic ptosis can resolve without intervention; an observation period of 3 months is recommended before considering functional or aesthetic correction.
• Rigorous clinical examination: Every practitioner operating on the facial skeleton must systematically test eyelid elevation and pupillary reactivity to rule out oculomotor nerve (III) involvement associated with bone fractures.

Technical lexicon of the study

Blepharoptosis (Ptosis): Drooping of the upper eyelid related to a failure of the levator structures. In this case of craniofacial trauma, it constitutes the major warning sign requiring a distinction between a mechanical origin and a neurological involvement.

Anisocoria: Inequality of pupillary diameter, a true neurological warning sign. The study reports here a fixed left pupil in intermediate mydriasis, contrasting with a reactive right pupil, pointing towards a lesion of the oculomotor pathways.

Glasgow Coma Scale (GCS): International scale for measuring the state of consciousness (from 3 to 15). A score of 15/15, as observed in this patient, may mask the severity of underlying structural lesions such as skull base fractures.

Temporal bone fracture: Rupture of the bone continuity of the lateral part of the skull base. Its bilateral presentation in this study highlights the extreme violence of the kinetic energy during the road traffic accident.

Subconjunctival hemorrhage: Localized blood effusion under the bulbar conjunctiva. Although often benign, its presence following facial trauma requires the rigorous exclusion of an eyeball wound or an orbital fracture.

Periorbital ecchymosis: Hematic infiltration of the soft tissues surrounding the orbit (commonly known as a black eye). It reflects the intensity of the facial trauma and, combined with oedema, often hinders the initial examination of ocular mobility.

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