Manuscript title: Transtympanic hijab pin injury: A rare cause of delayed-onset facial and cochlear nerve palsy with rehabilitative challenges in resource-limited settings: A case report.

INTRODUCTION: Penetrating transtympanic facial nerve injuries represent rare clinical entities, typically associated with thermal or iatrogenic causes. We present an exceptional case of combined facial and vestibulocochlear nerve injury from an unusual foreign body, highlighting diagnostic challenges and management dilemmas in resource-limited settings.

CASE PRESENTATION: A 17-year-old female presented with a 2-year persistent left facial paralysis following traumatic insertion of a hijab pin. Despite prior emergency surgery removing superficial fragments, she developed House-Brackmann grade V paralysis with associated severe sensorineural hearing loss (>60 dB).

CLINICAL DISCUSSION: Clinical evaluation revealed complete left facial nerve dysfunction: absent forehead wrinkling, incomplete eye closure, mouth deviation, and impaired oral competence. Neurologic examination demonstrated concurrent vestibulocochlear involvement with the lateralizing Weber test. High-resolution temporal bone CT and MRI revealed a retained metallic fragment extending into the internal auditory canal, with associated osseous disruption along the facial canal's tympanic segment. Given the irreversible neural damage, treatment focused on fitting a hearing aid which, improved auditory threshold to >30 dB, besides botulinum toxin injections for facial symmetry.

CONCLUSION: This case demonstrates how delayed treatment of transtympanic injuries leads to irreversible damage, stressing the urgency of early diagnosis. When surgery is no longer viable due to late presentation, rehabilitative options like Botox and hearing aids become options for treatment, particularly in resource-limited settings or tardy medical intervention.