TREATMENT
■ Initiate carbamazepineand analgesics in ED.
■ Outpatient referral to follow carbamazepine levels, CBC and liver func-
tion tests
Bell Palsy
A lower motor neuron (“peripheral”) CN VII palsy
CAUSES
Bell palsy is most commonly due to herpes virus infection.Pregnant women
are at greater risk. Other infections (HIV, Lyme disease) can also cause a CN VII
palsy.
SYMPTOMS/EXAM
■ Viral prodrome (50% of time)
■ Abrupt onset of unilateral facial paralysis with forehead included (central
causes will spare the forehead)
■ May also have loss of taste to anterior two-thirds of tongue, hyperacusis
(sound distortion or tinnitus)
■ Bell’s phenomenon: Eye rolls back in head when patient attempts to close
the lid
DIFFERENTIAL
■ Ramsay Hunt syndrome
■ Herpes zoster infection of geniculate ganglion
■ Characterized by facial paralysis, pain, tinnitus, hearing loss, and typi-
cal zoster lesions on the affected side, including inside external audi-
tory canal, and/or the tympanic membrane
■ Treatment = prednisone and antivirals.
■ Lyme disease
■ A leading cause of facial paralysis in regions where Lyme disease is
endemic
■ May be unilateral or bilateral
■ Diagnosed via serologic titers
■ Treatment = doxycycline PO.
■ Malignant otitis externa
■ Severe otitis externa that is typically seen in diabetes or immunocom-
promised patients
■ Pseudomonassp. often implicated
■ Requires IV antibiotic therapy and ENT consultation
■ Acoustic neuroma
■ Hearing loss accompanying facial weakness
■ MRI is diagnostic test of choice.
■ Other causes include temporal bone trauma, mononucleosis, HIV serocon-
version, other infectious organisms, mononeuropathy multiplex, Sjögren
syndrome.
DIAGNOSIS
■ Primarily a clinical diagnosis
■ Any evidence for sparing of upper face (“central” CN VII paralysis) warrants
CT or MRI to evaluate for stroke or CNS lesion.
NEUROLOGY