Chapter 13, Problem 4CCS

44-Year-Old Male with Skull Fracture

William Hancock, 44, fell from the scaffolding at a construction site. When emergency personnel arrived, they found him unconscious but with stable vital signs. As paramedics placed him on a backboard to stabilize his head, neck, and back, they noted watery blood leaking from his right ear. In the hospital, Mr. Hancock regained consciousness and was treated for deep lacerations on his scalp and face. Head CT scans revealed both longitudinal and transverse fractures of the right petrous temporal and sphenoid bones that extended through the foramen rotundum and foramen ovale.

The following observations were recorded on Mr. Hancock’s chart on admission:

•Complete loss of hearing in the right ear.

•Paresthesia (sensation of “pins and needles') at the right corner of the mouth, extending to the lower lip and chin.

•Numbness of the right upper lip, lower eyelid, and cheek.

•Right eye turned slightly inward when looking straight ahead. Diplopia (double vision), particularly when looking to the right.

Mr. Hancock was given a course of antibiotics, the head of his bed was elevated by 30 $°$, and he was placed under close observation. After 24 hours, doctors noted that the right side of Mr. Hancock's face showed signs of drooping, with incomplete eye closure and asymmetric facial expressions. Mr. Hancock's right eye showed minimal tear production. The weakness and asymmetry on the right side of his face began to subside after a few days, and the leak of fluid from his ear stopped, but he continued to complain of paresthesia, diploopia, and an inability to hear with his right ear.

4. NCLEX-STYLE The observations after 24 hours suggest that yet another cranial nerve has been damaged. Which of the following choices best explains the new observations including the lack of tear production?

a. The oculomotor nerve has been damaged, including its parasympathetic branch.

b. The facial nerve has been damaged, including its parasympathetic branch.

c. The oculomotor nerve has been damaged, including its sympathetic branch.

d. The facial nerve has been damaged, including its sympathetic branch.