EMCrit.org

Cranial Nerve Disorders

Trigeminal Neuralgia

Unilateral facial pain associated c non-painful triggers

2-4% also have MS

Rx c carbamazepine 100 mg po bid

 

Facial Nerve Paralysis (Bell's Palsy)

Bell’s Palsy

7th CN, post-infection, stapedius, lacrimation (epiphora-tears pooling on cheek), facial paralysis, anterior 2/3 of tongue, abnormally acute hearing.  Always think of lyme. 

Bell’s phenomenon-upward rolling of eyes when attempting to close lids.  Palpate parotid for swelling.  Usually complete recovery in 1 month. 

 

one of the more sensitive signs is that the patient may be able to blink both eyes, but will not be able to wink the affected eye in a Bell's

 

Consider temporal bone trauma in differential

 

Clinical characteristics of typical Bell's palsy include the following: peripheral CN VII dysfunction involving all distal branches; sudden onset with maximal facial weakness usually reached within several days; impaired result on acoustic reflex test in 90 percent; viral prodrome in 60 percent; numbness or pain of the ear, tongue, or face in 50 percent; chorda tympani nerve appears red in 40 percent; reduction in ipsilateral tearing or salivary flow in 10 percent; and spontaneous improvement within 6 months.(Otolaryngol Clin North Am 1991;24(3))

 

Prednisone 60 mg x 5, then 5 mg/day x 5 days or 1 mg/kg x 7 days with/without a taper

acyclovir 400–800 mg orally five times daily for 10 days. The newer oral antiviral agents such as valacyclovir and famciclovir have better oral absorption, are better tolerated, and have been recommended as alternatives to acyclovir (Valtrex 1g BID)

 

non-randomized trial use both within three days and get better outcomes than prednisone alone (Hato, N., et al, Otol Neurotol 24(6):948, November 2003)

 

Get Lyme Titers

Patch and lubricate affected eye.  Or have pt tape it closed at night

Ramsey Hunt Syndrome (Herpes Zoster Oticus)

 

Emergency physicians frequently encounter patients that present to the ED with facial nerve palsy.  The vast majority of patients who have a seventh nerve paralysis will have clinical Bell’s palsy.  The following pearls need to be kept in mind:

• Slowly progressive facial paralysis is suggestive of a neoplasm.

• Recurrent unilateral paralysis may occur with Bell’s palsy but is frequently (30%) seen in tumor patients.

• Simultaneous bilateral facial paralysis excludes Bell’s palsy as a diagnosis and is suggestive of Lyme disease.

• Patients who have facial muscle paresis with intact forehead movement should be considered to have an upper motor neuron lesion until proven otherwise.

• Lyme disease must be considered a possible cause, especially in endemic regions.

 

Emerg Med J 19:326, 2002

 

METHODS: The author of this paper, from the British series of "best evidence topic reports," performed a review of the literature to identify studies of the effect of acyclovir on functional recovery in patients with Bell's palsy. Two of 49 papers that were identified were felt to provide the best evidence regarding this topic.

RESULTS: In one study, 119 patients presenting within 72 hours after the onset of palsy were randomized to a ten-day course of acyclovir (2000mg daily) and prednisolone (1mg/kg for five days tapered to 10mg/day), or prednisolone alone. The combination treatment exhibited a small beneficial effect in the outcomes of motor recovery on visual assessment and partial nerve degeneration on electrical testing. In the second study, 113 patients presenting within 96 hours after the onset of palsy were randomized to a ten-day course of acyclovir (2400mg daily) or a 16-day course of prednisolone (1mg/kg for first ten days). In this study prednisolone was found to have a beneficial effect on the aforementioned outcomes. Neither study included an intention-to-treat analysis. A substantial number of patients was lost to follow-up, and there was no real placebo control group in the second study.

CONCLUSIONS: The available evidence provides no support for the use of acyclovir as monotherapy in patients with Bell's palsy, and suggests that a combination of prednisolone plus acyclovir might have a small benefit in terms of functional recovery when compared with prednisolone alone.

May offer benefit in the long term for full recovery Valtrex 1 g tid for 1 week and prednisone 50 mg OD for 1 week (Ann Otol Rhono Laryngol 112:197, 2003)

 

Recurrent or bilateral facial palsy should prompt consideration of myasthenia gravis or lesions where the facial nerve exits the pons; such types of palsy occur in lymphoma, sarcoidosis, and Lyme disease (NEJM, 9/23/04, pg. 1323).

 

Treatment of Bell's Palsy - The Latest
from emedhome.com


Treatment of Bell's palsy remains controversial and variable. The detection of herpes simplex virus in the endoneural fluid of patients with Bell's palsy suggests an association between herpes infection and the onset of facial paralysis (1). Corticosteroids and antiviral agents are commonly prescribed separately and in combination, although evidence of their effectiveness is weak. Two recent Cochrane reviews assessed the effectiveness of corticosteroids and antiviral agents in patients with Bell's palsy and independently concluded that insufficient data exist to support the use of either or both therapies (4,5).

A large, randomized, controlled trial of the efficacy of treatment for Bell's palsy appears in the current issue of the New England Journal of Medicine (2). The study confirmed the generally favorable outcome for patients receiving double placebo, with 65% of patients fully recovered at 3 months and 85% at 9 months. Early treatment (within 72 hours of symptom onset) with prednisolone increased these rates to 83% and 94%, respectively. Acyclovir produced no benefit over placebo, and there was no benefit in its addition to prednisolone. In the US, oral prednisone (1 mg/kg for 7 - 10 days) is typically prescribed (3).

The accompanying editorial notes that although acyclovir does not appear to be of benefit, valacyclovir in combination with glucocorticoids could still be considered in patients with severe or complete facial palsy (3). Valacyclovir is a prodrug that is nearly completely converted to acyclovir and L-valine and has substantially increased bioavailability, as compared with acyclovir. A recent study suggests that the use of valacyclovir in combination with glucocorticoids should be considered in patients with severe or complete facial palsy; there is expert opinion that agrees with this view, noting that there likely is no benefit of antiviral therapy in patients with moderate palsy (3,6).

No good data are currently available regarding how best to treat patients who present more than 72 hours after the onset of symptoms (2).


References:

(1) Murakami S, at al. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle Ann Intern Med 1996;124:27-30.
(2) Sullivan FM, et al. Early treatment with prednisolone or acyclovir in Bell's palsy N Engl J Med 2007;357:1598-1607.
(3) Gilden DH, et al. Bell's palsy - is glucocorticoid treatment enough? N Engl J Med 2007 Oct 18;357(16):1653-5.
(4) Salinas RA, et al. Corticosteroids for Bell's palsy (idiopathic facial paralysis) Cochrane Database Syst Rev 2004;4:CD001942-CD001942.
(5) Allen D, et al. Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis) Cochrane Database Syst Rev 2004;3:CD001869-CD001869.
(6) Hato N, et al. Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter, randomized, placebo-controlled study Otol Neurotol 2007;28:408-413.

 

Patients with hypertension, impaired taste, pain other than in the ear, and complete facial weakness all carry a poor prognosis (ACP Journal Club, March/April, 2008, pg. 29).

 

Ramsay Hunt Syndrome

Central Venous Thrombosis

 

Multiple Sclerosis (MS)

characterized by lesions separated in space and time.  Internucleur opthalmoplegia-can’t adduct eye, c nystagmus

IV Solumedrol during attacks