1. Case Presentation
by Michael Armstrong

2. Chief Complaint
My face is numb on the right side, my vision is blurry, and I can’t 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, TM’s and canals clr., good acuity b/l, nares patent, septum midline, MMM&P, pharynx clr., MMM&P, 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 Bell’s Palsy
CT of the head
Lyme titers

13. Differential Diagnosis
Ramsay Hunt Syndrome
Acoustic Neuromas
Heerfordt’s Syndrome
Melkersson-Rosenthal Syndrome

14. Bell’s 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)
Harrison’s Principals of Internal Medicine