3- Head and Facial Disorders Flashcards
What is the most common etiology of facial palsy?
Idiopathic
What are the RFs for Bell’s Palsy?
Pregnancy and DM
(pregnancy also increased recurrence rate)
Pt presents w/ sudden onset (w/i hours) of unilateral facial paralysis with inability to close eye. On PE you note facial drooping with flattening of nasolabial fold, decreased tearing, and hyperacusis. What are you concerned for?
Bell’s Palsy
How could you r/o Herpes zoster/ Ramsay Hunt syndrome as a ddx for Bell’s palsy?
Vesicles + preherpetic neuralgia
How could you r/o lyme disease as a ddx for Bell’s palsy?
Bilateral (lasting less than 2 months)
*eval if young pt*
How could you r/o Guillain-Barre as a ddx for Bell’s palsy?
Bilateral
(+ progressive and symmetric)
How could you r/o a tumor as a ddx for Bell’s palsy?
Gradual onset (2+ weeks)
How could you r/o a stroke as a ddx for Bell’s palsy?
Spares forehead
Pt presents with suspected Bell’s palsy. Are you concerned for peripheral or central facial palsy? LMN or UMN lesion?
Peripheral, LMN
Affects ipsilateral face with FH involvement
Pt presents with suspected stroke or tumor. Are you concerned for peripheral or central facial palsy? LMN or UMN lesion?
Central, UMN
Affects contralateral face with NO FH involvement
How is Bell’s palsy diagnosed?
Clinically- diffuse facial nerve involvement + acute onset 1-2 days
When would diagnostic studies/ imaging be considered for Bell’s palsy?
Atypical sxs
No significant improvement in 4 months
Progression beyond 3 weeks
In addition to possible EMG, NCS, CT/ MRI, what labs should be ordered for workup of Bell’s Palsy (if indicated)?
Serologic testing for Lyme disease/ HSV
What is the pharmacologic tx recommended for ALL pts with Bell’s Palsy?
Prednisone +/- Valacyclovir iniated w/i 3 days of sxs
Due to increased risk of drying, corneal abrasion, or corneal ulceration, what else should be included in the management for Bell’s Palsy?
Eye care
(artificial tears, eye ointments, sunglasses)
Pt with hx of Bell’s Palsy presents with blinking causing a twitch in the corner of the mouth and winking with smiling. What should you tell them?
New axon growth may be disorganized/ synkinesis
Pt presents with recurrent, brief episodes of severe, unilateral shooting pain along the 5th CN (V2/V3) lasting a few seconds. They describe the pain as an electrical, shock-like sensation and note it is triggered with light touch. Sxs began with continuous, dull ache in jaw. On PE you note patient guarding. What are you concerned for?
Trigeminal neuralgia (aka “tic doulaureux”)
(continuous, dull ache in the jaw = retrigeminal neuralgia (“aura”))
How is trigeminal neuralgia classified?
Classic
Idiopathic
Secondary- r/o MS, painful trigeminal neuropathy- causes attributing to nearly continuous sxs
Trigeminal neuralgia typically afects V2 and/ or V3. What type of sxs might you notice if V1 is affected?
Autonomic
How long do episodes of remission last for trigeminal neuralgia and what is important to note about recurrence?
Remissions 6+ months
Recurrence more frequent and more disabling
According to the internaltional classification of HA disorders, how is trigeminal neuralgia diagnosed?
3+ episodes, CN V dist. only, no neuro deficits
Clinical suspicion for trigeminal neuralgia should be followed by eval for secondary causes with what imaging study?
MRI with and without contrast
What is included in the pharmacologic (1st line) management for TN?
Carbamazepine (increase gradually w/ maintenance dose)
Anticonvulsants (if Carbamazepine unable to tolerate or ineffective)
Baclofen (alone or in combo)
What are the SEs for Carbamazepine (tx of TN) and what must you monitor because of these SEs?
Drowsiness, dizziness, N/V, leukopenia, aplastic anemia
Monitor CBC
When should surgery be used to treat TN?
Refractory to meds
(microvascular decompression, ablation)
Ophthalmic artery occlusion (a/w GCA) leads to what clinical manifestation?
Blindness
Basilar artery occlusion (a/w GCA) leads to what complication?
Brain stem infarct
What are the RFs for GCA?
Polymyalgia rheumatica
Increased age (avg ~ 77 yo)
Pt presents with new onset HA, diplopia, transient blindness (amaurosis fugax), and jaw claudication. On PE you note tenderness to temporal artery and neck/ shoulder muscles. What are you concerned for?
(amaurosis fugax: cannot see out of one/ both eyes due to lack of blood flow)
GCA
What is the most useful screening tool for GCA?
ESR
(will be elevated)
How is GCA diagnosed?
Temporal artery biopsy; multi-nucleated cells
(1-2cm due to possible “skip lesions”)
What is the goal in management for GCA and what is prescribed?
Prevent blindness/ stroke
High dose prednisone (taper slowly, start prior to confirming dx if high suspicion)
Who is at an increased risk of TMJ dysfunction?
Rheumatoid arthritis
Pt presents (20-40 yo) with periauricular pain and tenderness of TMJ/ muscles of mastication. They also report HA/ ear discomfort and radiating pain. On PE you note decreased jaw ROM, clicking or popping with movement, and abn dental wear. What are you concerned for?
TMJ dysfunction
How is TMJ dysfunction diagnosed/ treated?
Clinical dx (further eval if systemic sxs)
Tx: dental referral
+/- sxs relief (heat, soft diet, jaw exercises, NSAIDS if chronic pain)
Pt with suspected TMJ is in extreme pain, has abn x-rays, changes in CNs, or previous surgery to TMJ. What is indicated?
CT/ MRI
What tx is considered if TMJ dysfunction is refractory?
Trigger injections, surgery
