Bell's Palsy And Trigeminal Neuralgia (Lauren🌭) Flashcards
What are some of the possible causes of facial palsy?
IDIOPATHIC**
Infections
Traumatic
Tumor
Stroke
Toxins
What are the functions of the facial nerve that may get messed up if you have Bell’s palsy
Facial expression😖
Staepedius muscle📢
Lacrimal and salivary glands😢
Taste to front 2/3 of tongue👅
What causes Bell’s palsy?
Unknown, but we think HSV might have something to do with it
What are 2 conditions that increase your risk of developing Bell’s Palsy?
Pregnancy, especially 3rd trimester or immediately post partum 🤰🏻
Diabetes 🧁
Bell’s palsy develops (Suddenly/gradual)
Suddenly.
Patients often wake up with it and notice it when they look in the mirror to brush their teeth
What will someone with Bell’s palsy look like?
🐝🐝🐝🐝🐝
Unable to CLOSE eye
Forehead does NOT wrinkle on that side
Facial drooping with flattening of nasolabial fold
Decreased tears
Hyperacusis (due to stapedius muscle)
+/- loss of taste to anterior 2/3 of tongue
What are 5 possible things that need to be on your differential when someone presents with Bell’s palsy symptoms?
Herpes zoster: Ramsay Hunt syndrome
Otitis Media
Lyme disease
Guillan-Barre
Tumor
Stroke (central lesion)
How would you know if it’s due to herpes zoster (Ramsay Hunt Syndrome)
Vesicles near external meatus
Preherpetic neuralgia (painful prodrome)
How would you know if someone’s facial drooping was due to Lyme disease?
It would probably be bilateral
They might have erythema/swelling prior to the palsy
How would you know if someone’s facial drooping was due to guillain-barre?
It would be bilateral and progressive
How would you know if someone’s facial drooping was due to a tumor?
It would have a gradual onset
How would you know if someone’s facial drooping was due to a central stroke?
They WILL be able to wrinkle their forehead!!****
(Of course you can’t completely rule out stroke if they can’t wrinkle forehead, but for the purposes of this exam you probably can)
Central or peripheral facial palsy:
UMN lesion affects contralateral portion of the lower face
Central
Central or peripheral facial palsy:
LMN lesions afffescts the ipsilateral side of the face
Peripheral
Central or peripheral facial palsy:
Forehead spared (can wrinkle forehead)
Central
Central or peripheral facial palsy:
Involves forehead (can’t wrinkle forehead)
Peripheral
Central or peripheral facial palsy:
Stroke
Tumor
MS
Trauma
Central
Central or peripheral facial palsy:
Bell’s palsy
Guillan barre
Otitis media
Lyme
Ramsay hunt syndrome
Peripheral
What is the name for herpes zoster that affects the facial nerve and causes facial drooping?
Ramsay hunt syndrome
True or false:
Bell’s palsy is a clinical diagnosis
True.
Based on:
1. Diffuse facial nerve involvement (forehead and eye affected)
- Acute onset in 1-2 days. Maximum severity within 3 weeks. Improvement or recovery in 6 months
If Bell’s palsy is not getting better in _________weeks, you need to start looking for some other cause
3
When would you need to do diagnostic studies for someone with Bell’s palsy?
Getting worse after 3 weeks
No significant improvement in 4 months
Atypical symptoms
What kinds of diagnostic studies can you do to work up weird Bell’s palsy?
Serologic testing for Lyme and HSV
Fasting blood glucose
EMG/NCS
CT/MRI
If you suspect Bell’s palsy and your patient tests positive for HSV, that will (support/hurt) the diagnosis of Bell’s palsy
Support
What is the pharmacological management of Bells Palsy?
Prednisone 60-80mg x 7 days (or some crazy tapering dosage)
+/- Valacyclovir 1g TID x 7 days
Best results if tx initiated within 3 days of onset
You should start prednisone and valacyclovir within _____ days of symptom onset for Bell’s palsy
3
Do you need to do anything else for Bell’s palsy patients other than prednisone and valacyclovir
EYE CARE
🌵👁
(They cant close one eye)
How do you keep someone’s eye from drying out if they have Bell’s palsy?
Artificial tears every hour during the day
Eye ointments at night +/- patch
Sunglasses 😎
How long will it take for someone with Bell’s palsy to return to normal function?
3-6 months
What is the fancy name for trigeminal neuralgia?
Tic doulaureux
Trigeminal neuralgia pain is described as:
attacks of electrical shock-like pain that lasts a few seconds and can occur repetitively
Episodes happen daily or several times a month
Episodes of remission last for 6+ months
What age is typically diagnosed with trigeminal neuralgia?
> 50
Overall, what causes Trigeminal neuralgia?
Compression of trigeminal nerve that causes demyelination
What are the 2 classifications of trigeminal neuralgia?
Classic- idiopathic or vascular compression
Secondary/painful trigeminal neuropathy- compression is caused by other reasons (Multiple sclerosis, herpes zoster, vestibular Schwannoma, meningioma, cyst)
Trigeminal neuralgia is usually (unilateral/bilateral)
Unilateral
Which branches of CNV are usually affected by trigeminal neuralgia?
V2 and V3
If V1 is affected by trigeminal neuralgia, what other symptoms would you expect to see?
Autonomic symptoms (which would make it look like a cluster headache)
What can trigger an attack of trigeminal neuralgia?
Light touch
Chewing
Talking
Shaving
Brushing teeth
Cold air
What is pretrigeminal neuralgia?
Prodrome of an achey jaw prior to an attack of trigeminal neuralgia
(People often go to the dentist)
What kind of imaging do you NEED to do when someone shows up with symptoms of trigeminal neuralgia?
MRI brain with and without contrast
Maybe an MRA to look for vascular compression if they have the classic presentation
What is the pharmacologic treatment for trigeminal neuralgia?
Carbamazepine 100-200mg BID
Increase gradually to 600-800mg total daily
What are the side effects of carbamazepine?
Drowsiness
Dizziness
N/V
Leukopenia
Aplastic anemia
What lab test do you need to monitor when someone is on carbamazepine?
CBC (due to the risk of leukopenia and aplastic anemia)
What genetic test do you need to do before you start someone on carbamazepine, especially Asian patients?
HLA-B 1502 due to the risk of Stevens Johnson Syndrome
What treatments other than carbamazepine may be helpful for trigeminal neuralgia?
Other anticonvulsants (oxcarbazepine, gabapentin, phenytoin, Lamotrigine)
Baclofen can be used alone OR in combo with carbamazepine
Topical lidocaine
Opioids (require high dose, just dont do this ok?)
What two titers should be drawn when a patient presents with Bells Pasly?
Herpes simplex
Lyme
What 2 clinical conditions increase the risk for Bell’s palsy
Pregnancy
Diabetes
A patient has a flat nasolabial fold, cant close his right eye, and cant wrinkle the right side of his forehead. On exam you note vesicles in the right ear canal. What is the diagnosis =
Ramsay Hunt Syndrome
A patient presents with jaw pain, no trauma, ROM is diminished with attempts to open the mouth. What is the diagnosis?
TMJ dysfucntion
What neurological condition os most commonly seen with trigeminal neuralgia:
A. Myasthenia gravis
B. Guillan barre
C. Parkinson’s
D. Multiple Sclerosis
D. Multiple Sclerosis
What rheumatic condition may be associated with giant cell arteritis?
Polymyalgia rheumatica
What is the treatment of choice for Giant Cell arteritis?
High dose oral steroids
