35 year old male'Doctor, am I having a stroke? Do I need a scan of my brain'?
What medications would you prescribe? How would you prognosticate his illness?
Answer : Bell's palsy (on the left side)
This is a rather common case we see in the ER, and patients are invariably frightened that they are having a CVA. Bell's palsy is an idiopathic lower-motor neurone (LMN) palsy affecting the facial nerve (7th cranial nerve).
The main clinical signs are illustrated here:
Let's review the difference between upper & lower motor neuron lesions of the 7th nerve:
- In general, due to the cross-innervation of nerve fibres, a LMN lesion results in paralysis or weakness of both upper and lower parts of the face, whereas an upper motor neuron (UMN) lesion usually spares the upper part of the face (i.e patient can wrinkle forehead on that side). Note however that this is not always absolute.
- Other signs to look for (more for exam purposes):
- Inspect ear and do otoscope to look for vesicles (Ramsay-Hunt Syndrome)
- Test taste function (chorda tympani involvement)
- Check for hyperacusis (nerve to stapedius involvement)
Treatment
- Prednisolone (1mg/kg BW, up to 60 mg/day) for 7-10 days - recent trials have shown significant improvement in outcome if started within 72 hrs of symptom onset
- Acyclovir - benefit is less certain compared to steroids.
- Eye protection - artificial tears and taping of eye at night if it cannot be voluntarily closed
- Refer to neurologist/ ENT for further follow-up.
- 85% complete recovery, 10% residual deficits, 5% severe sequelae
- Poor prognosticating factors include:
- Older patients
- History of recurrent facial nerve palsy
- Complete facial paralysis during the acute phase
- Longer time taken to recover
- Presence of postaurticular pain, abnormal taste, tearing
- Diabetic patients
- Pregnant patients
No comments:
Post a Comment