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Morning Report

2/6/19
Ted Tanner, MD MPH MA
At Urgent Care

• Mom reports, “He can’t close his left eye and the left side of his face is
droopy. That polio-like virus is at his school.”
• T. 36.9, HR 75, BP 107/52, RR 26, SpO2 97
• Ht. 129.5cm Wt. 28.4 kg, BMI 16.93
HPI
• 9-year-old male with 1 day of inability to close left eye and facial
asymmetry with smiling.
• Patient also reports slight blurry vision when watching TV or playing
video games.
• Mom reports he had a mild URI-type illness for a few days about 1.5
weeks ago.
• He denies headache, photophobia, phonophobia, upper or lower
extremity numbness or weakness, and gait instability.
• ROS: As reviewed in the HPI.
• PMHx: Eczema, constipation, non-celiac gluten sensitivity, born
term, no surgeries or hospitalizations
• Meds: None
• Allergies: NKDA
• Family HX: non-contributory
• Social: 4th grade, lives with mom and younger brother. Sees dad a
few times a month. No tobacco exposure.
• Immunizations: UTD, no flu shot this year
• Constitutional: alert, interactive, non-toxic
• HEAD: normocephalic, atraumatic. No visible forehead wrinkles with attempted
elevation of left eyebrow
• NECK: supple without meningismus, no LAD, FROM
• EYES: left eye ptosis, EOMI, conjunctivae clear, PEERLA
• EARS: TMs clear. No redness or swelling.
• NOSE: No rhinorrhea
• MOUTH: moist mucus membranes, no lesions. When smiling, the patient is unable
to raise the left side of his mouth, disappearance on nasolabial fold
• RESP: CTAB
• CV: RRR, no murmurs, Normal cap refill, good pulses
• GI: Abdomen soft, NT, ND, no organomegaly
• MSK: No joint swelling or pain. FROM in upper and lower.
• SKIN: no rashes or lesions
• NEURO: Normal mental status. Normal strength, and tone in the extremities. Facial
weakness noted on the left side. Unable to close left eye fully or raise the left
eyebrow.
Thoughts?

• There’s more to the story.


• What cranial nerve is involved?
• Facial Nerve (CNVII) Palsy
• Bell’s palsy is commonly used to describe
peripheral facial palsy of unknown cause
• Sir Charles Bell, a Scottish surgeon, described
function of the facial nerve in the early 1800s
• His initial description of facial palsy related to
paralysis of the facial nerve due to trauma
Epidemiology
• Bell’s Palsy (idiopathic) makes up about ½ of all facial nerve palsies
• Annual incidence is between 13 and 24 per 100,000
• No increased risk based on gender, race, or geographic location
• 3x greater risk in pregnant especially 3rd trimester
• 5-10% of patients have diabetes
Etiology

• HSV believed to be #1 cause of all cases, though hard to confirm


• In children, #1 overall is AOM
• Lyme disease is most common in endemic areas
– Delaware study of 50 children with facial palsy
– 50% Lyme disease. 12% AOM, 26% Bell’s, VZV 6%
• Mumps is a common cause in endemic countries. Parotiditis compresses the nerve.
• Congenital facial nerve palsy
– Facial dysmorphia, forceps delivery, prematurity, LGA
Lyme Disease
• Most common cause of acute facial nerve palsy in endemic areas
• Most common neuropathy associated with Lyme
• Direct invasion of the nerve by Borrelia burgdorferi
• Facial nerve palsy may be the only clinical finding
• Painless, non-tender swelling and erythema of face preceding palsy
are distinctive of Lyme disease
Clinical Features
• Sudden onset, usually over hours, unilateral facial paralysis
• Decreased forehead movement, sagging of eyebrow, inability to
close eye, disappearance of nasolabial fold, drawing of mouth to
the unaffected side
Clinical
Features

• (A) Demonstrates inability to raise the


left eyebrow or generate wrinkles on the
left side of forehead;
• (B) Demonstrates difficulty closing the
left eye and inability to raise the left corner
of mouth;
• (C) Demonstrates drooping at the left
corner of mouth, loss of the left nasolabial
fold, and inability to completely close the
left eye.
Clinical Features
• Decreased tearing, hyperacusis, and/or loss of taste to anterior
2/3rds of tongue indicate more severe disease
• Abducens (CN VI) palsy, lateral rectus palsy (inability of eye to turn
outward) suggests brainstem lesion.
– CN VI nuclei in close proximity to where VII exits the brainstem
Central vs.
Peripheral Lesions
• Stroke vs. something far less scary
• Sparing of forehead muscles is
suggestive of central (upper motor
neuron lesion). There is bilateral
innervation to this area.
Diagnosis
• Diffuse facial nerve involvement:
– Paralysis
– +/- loss of taste from ant. 2/3 of tongue
– +/- altered secretion from lacrimal and salivary glands
• Acute onset: hours to days
• There may be an associated prodrome: ear pain or hearing
impairment
Diagnosis
• Lyme serologies for exposed children
• Nerve conduction studies for complete lesions
• Pre-post contrast enhanced MRI for atypical physical findings:
chronic otitis media, acute mastoiditis, temporal bone trauma,
suspected neoplasm, or if progression is slow and beyond three
weeks or no improvement at 6 months
• LP if clinical suspicion of meningitis (severe HA, fever, meningismus,
papilledema)
– May see slight increase in monocytes and lymphocytes with
Bell’s
Glucocorticoids +/- antivirals
For severe palsy or known HSV
All children, prednisone 2mg/kg up to
exposure: valacyclovir 20mg/kg/dose
60-80 mg daily for 5 days
TID, max 1g/dose, for 7 days

Treat underlying cause


Treatment (Lyme disease, otitis)

Eye Care
artificial tears during day and
ophthalmic ointment + patching at night
Congenital facial palsies = poor

Traumatic paralysis in perinatal period =


great

Prognosis
Idiopathic or infectious = great
Prognosis most favorable if some recovery is
Clinical incomplete lesions tend to recover
seen within the first 21 days from onset

Recurrence in children is <10%


Recurrence suggests diagnosis other than Bell’s (eg. Hypertension)