20/9/21

Question 1

Causes of Facial Weakness - Categories

Answer 1

Inflammatory
Infectious
Neoplastic
Otologic
Neurological
Idiopathic
Trauma

Question 2

Causes of Facial Weakness (20 points - give me 5)

Answer 2

Neurological

• Stroke (upper motor neuron palsy)
• Multiple Sclerosis
• Guillain-Barre Syndrome

Otologic

• Acute or Chronic Otitis Media
• Severe Otitis Externa
• Cholesteatoma
• Schwanomma

Infectious

• Herpes Zoster Virus
• EBV
• Mumps
• Rubella

Inflammatory
- Sarcoidosis

Neoplastic

• Cerebral Tumour
• Parotid Tumour
• Metastatic Tumour
• Lymphoma
• Cutaneous cancer of the face and neck

Idiopathic
- Bells Palsy

Trauma

• Temporal Bone Fracture
• Surgical intervention with damage to the facial nerve

Question 3

Diagnosis if Facial Weakness + vesicles in the ipselateral ear

Answer 3

Varicella Zoster Infection of the Facial Nerve aka Ramsay Hunt Syndrome

Question 4

Treatment of Bells Palsy (also timeframe)

Answer 4

IF SYMPTOMS <72 hours -> prednisolone 1mg/kg (up to 75mg) orally, once daily in the morning for 5 days

Question 5

Additional treatment for Ramsay Hunt Syndrome

Answer 5

add anti-viral drug (valaciclovir 1g PO TDS for 7/7) onto prednisolone 1mg/kg orally OD for 5/7

Question 6

Simple pathogenesis of shingles + demographic of patients with shingles

Answer 6

Caused by reactivation of varicella zoster virus
Uncommon in childhood → incidence increases with age
- majority of patients are not immunocompromised but in immunocompromised patients → multidermatomal rash can complicate infection

Question 7

Clinical Presentation of Shingles (2 points)

Answer 7

• rash that presents in blisters in a dermatomal distribution on an erythematous base
• Blisters erupt over 1 week and heal over 2 weeks

Question 8

In shingles, if we commence anti-virals within 72 hours, what are the 4 benefits we get?

Answer 8

1. Reduce acute pain
2. Duration of the rash
3. Viral shedding
4. Reduce risk of ccular complications

Question 9

Who gets anti-viral therapy for shingles?

Answer 9

Antiviral therapy is recommended for all patients who present within 72 hours of the formation of the rash or for immunocompromised patients at ant time regardless of duration of the rash.

Question 10

What is the anti-viral therapy for shingles? Be Specific.

Answer 10

valaciclovir 1g TDS for 7/7 (children >2yo -> 20mg/kg up to 1g)

Question 11

Pain Relief for Acute Herpes Zoster Pain (4 steps)

Answer 11

1. Paracetamol 1g PO Q4-6H PRN up to max 4g daily
2. if pain severe → Prednisolone 50mg daily mane for 7/7, then taper over 14 days then cease → can reduce duration of pain in combination of anti-viral drug

• Alternatives for severe pain:
  1. Amitryptilline 10-25mg PO nocte, increasing every 7 days to usual maximum dose of 75mg nocte
  2. OR opioid orally → usual principles of opioid prescribing apply → can start with endone 5mg Q4H