Case Presentation

1
Case Presentation

• by Michael Armstrong

2
Chief Complaint

• My face is numb on the right side, my vision is
  blurry, and I cant close my right eye.

3
History of present illness

• Patient is a 39 y/o Hispanic female with a 2 day
  complaint of numbness to the right side of her
  face following an aching pain in the right
  posterior auricular space. The numbness has
  progressed to the point where the patient has
  blurred vision and can no longer close her right
  eye.

4
HPI cont.

• The patient states her right eye tears a lot and
  she drools from the right side of her mouth. She
  also admits to having difficulty eating and
  drinking even with a straw. She states Motrin has
  helped with the pain. She denies weakness to her
  extremities, loss of consciousness, or head
  trauma.

5
Past Medical History

• Hypothyroidism
• Sarciodosis

6
Medications

• Synthroid

7
Allergies

• NKDA
• NKFA

8
Vital Signs

• BP 166/102
• HR 84
• RR 16
• Temp 98.0
• Ht 68 inches
• Wt 204 lbs

9
Physical Exam

• Gen Pt. A/O x 3 w/ Rt. side facial droop
• HEENT NC/AT, PERRLA, red reflex b/l, EOM
  intact, ptosis of rt. eye, light reflex b/l,
  disc margins sharp, no A-V nicking, TMs and
  canals clr., good acuity b/l, nares patent,
  septum midline, MMMP, pharynx clr., MMMP,
  throat supple, trachea midline, no
  lymphadenopathy.

10
Physical Exam

• Thorax Symmetrical w/ equal expansion, breath
  sounds vesicular and CTA b/l.
• CVA Normal S1,S2 w/ no murmurs, rubs, or
  gallops. No JVD.
• EXT No edema. Good pulses x 4 extrem.

11
Neurological

• Mental Status Alert and oriented
• Cranial Nerves I VI intact VII rt. side
  sens/mtr deficit VIII XII intact
• Motor Strength 5/5 throughout. Gait normal.
• Sensory Romberg neg., pinprick, light touch,
  position, vibration, and stereognosis intact.
• Reflexes Bi, tri, sup, abd, knee, ankle, pl 2

12
R/O Bells Palsy

• CT of the head
• Lyme titers

13
Differential Diagnosis

• TIA
• Ramsay Hunt Syndrome
• Acoustic Neuromas
• Heerfordts Syndrome
• Melkersson-Rosenthal Syndrome

14
Bells Palsy

• Described by Sir Charles Bell in the 19th
  century.
• Idiopathic form of facial paralysis resulting
  from inflammation of the facial nerve.

15
Epidemiology

• 40,000 to 50,000 Americans annually.
• May occur at any age.
• More common amongst pregnant women and those
  suffering from diabetes, influenza, common cold,
  or some other upper respiratory ailment.
• Occurs more often in spring or fall.

16
Pathophysiology

• Etiology unknown
• Some research leans towards herpes virus as a
  cause
• Sarcoidosis and Lymes Disease also potential
  causes

17
Signs and Symptoms

• Unilateral facial paralysis
• Inability to close the eye
• Absence of the nasolabial fold
• May be loss of taste on anterior tongue

• Pain behind the ear
• Tearing
• Drooling
• Hyperacusis
• Sag of the eyebrow

18
Diagnosis

• Based on clinical findings
• Imaging studies used to rule out other pathology
• Lyme titers, PCR testing may indicate cause

19
Treatment

• Corticosteroids (efficacy not proven)
• Analgesics
• Lubricating eye drops
• Taping eye closed at night
• Massage of the weakened muscles

20
Prognosis

• Generally very good
• Most patients get significantly better in about 2
  weeks even without treatment
• 80-85 recover completely within 3 months
• 10 have permanent disfigurement or other long
  term sequelae

21
References

• National Institute of Neurological Disorders and
  Stroke (online)
• National Institute of Dental and Craniofacial
  Research (online)
• Merck Manual (online)
• Harrisons Principals of Internal Medicine