Bells Palsy risk factors? 5

1. DM 2. immunocompromised 3. pre-eclampsia 4. recent URI 5. recent pfizer vax

Bells Palsy differentials 8

Herpes Zoster Lyme Disease Benign Facial Nerve Tumor Malignant Facial Nerve Tumor Delayed onset palsy from facial trauma chronic otitis media or cholesteotoma otitis externa CVA

Bells Palsy & Trigeminal Neuralgia Flashcards by Mikaela Koller

Bells Palsy

what is the most common etiology?

unilateral facial nerve palsy

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Bells Palsy

epidemiology (age, gender, seasonality)

usually adults, peak ages 20-40 y/o
men and women equally affected
rarely occurs in the summer

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Bells Palsy

risk factors?

DM
immunocompromised
pre-eclampsia
recent URI
recent pfizer vax

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Bells Palsy

differentiate upper and lower motor neuron lesions

UMN: lesions affecting the corticobulbar tract
LMN: lesions affecting individual branches

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Bells Palsy

pathophys

may affect any/all four fiber types carried by facial nerve
* somatomotor axons to facial muscle (presents as facial weakness)
* axons supplying stapedial muscle (hyperacusis)
* gustatory fiber insult (hypo or dys geusia)
* sensory fiber insult (otalgia and post-auricular pain, lacrimal/salivary gland dysfunction)

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Bells Palsy

describe the HSV hypothesis

cause causing primary infection on the lips (cold sores), the virus travels up sensory nerve axons and then reactivates and causes damage to myelin

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Bells Palsy

may be secondary to?

autoimmune reactions that cause facial nerves to demyelinate

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Bells Palsy

within how long do sx evolve?

72 hours

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Bells Palsy

presentation of illness

5 components

unilateral facial palsy of acute onset
ipsilateral post-auricular pain, mild to mod otalgia, hyperacusis, or phonophobia
hypo or dysgeusia
subjective tongue or facial hypoesthesia

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Bells Palsy

PE Exam components which will be unremarkable

focused neuro exam
complete head/neck exam (CN exam, otoscopy, tuning fork exams)

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Bells Palsy

what is Bell Phenomenon

L eye rolls upward and inward

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Bells Palsy

which side of the face is usually affected?

R side of the face

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Bells Palsy

sparing of the brow on PE indicates?

upper motor neuron lesion

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Bells Palsy

essentials of dx

3 essentials +/- 2 others

sudden onset of lower motor neuron facial palsy
hyperacusis or impaired taste
no other neurologic abnormalities
post-auricular pain or trigeminal neuralgia

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Bells Palsy

diagnosis to exclude

facial palsy of known etiology or a palsy that is progressive, waxing, waning, or affects facial zones in an uneven fashion

IS NOT BELLS PALSY

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Bells Palsy

what would uneven distribution of weakness indicate?

neoplasm

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Bells Palsy

what if it was vesicular palsy?

zoster

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Bells Palsy

diagnostics

3 components

“if it looks like a horse, it’s probably a horse”
imaging PRN to r/o stroke or neoplasm
Lyme testing if indicated

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Bells Palsy

differentials

Herpes Zoster
Lyme Disease
Benign Facial Nerve Tumor
Malignant Facial Nerve Tumor
Delayed onset palsy from facial trauma
chronic otitis media or cholesteotoma
otitis externa
CVA

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Bells Palsy

Tx (firstline)

corticosteroids w/in 72 hrs of sx osnet
burst and toper
Anti virals (if HSV; valacyclovir or acyclovir)

Bells Palsy

tx: eye protection

artificial tears during the day
tape shut at night w/ lubricant

Bells Palsy

where to refer for severe cases?

neuro-opthalmologist
neurologist

Bells Palsy

recovery for incomplete vs complete paralysis

incomplete paralysis: 94% recovery
complete paralysis: 61% recovery

Bells Palsy

poor prognosis w/

4 things

advanced age
DM
taste disturbance
pregnancy

# Bells Palsy follow up

within 1-2 wks to monitor response to therapy and follow condition of affected eye

# Trigeminal Neuralgia AKA

tic douloureux

# Trigeminal Neuralgia epi (gender, age, risk factor)

* more common in females than males * usually begins after age 40 (most common onset 60-70 yrs) * HTN is risk factor

# Trigeminal Neuralgia etiology

unclear and likely multi factorial

# Trigeminal Neuralgia essentials of diagnosis | 3

* brief episodes of stabbing facial pain * pain is in the territory of the 2nd and 3rd division of the trigeminal nerve * pain is exacerbated by touch

# Trigeminal Neuralgia which CN is attaked and causing stabbing facial pain?

* CN V

# Trigeminal Neuralgia International Headache Society Classifications

A: paroxysmal attacks of pain lasting from a fraction of a second to 2 min, affects 1+ divisions of trigeminal nerve B: pain is at least: intense/sharp/superficial/stabbing OR precipitated from trigger areas/factors C: attacks stereotyped in the individual pt D: no clinically evident neurologic deficit E: not attributed to another disorder

# Trigeminal Neuralgia where does pain shoot from in 60% of pts?

from corner of mouth to angle of jaw

# Trigeminal Neuralgia where does pain commonly run?

along line dividing either mandibular and maxillary nerves or maxillary and ophthalmic portions or nerve

# Trigeminal Neuralgia where does pain jolt from in 30% of cases?

* upper lip or canine teeth to eye/eyebrow * spares the orbit itself

# Trigeminal Neuralgia fewer than 5% of cases involve what?

ophthalmic branch

# Trigeminal Neuralgia triggers | 4

1. chewing, talking, smiling 2. drinking hold/cold fluids 3. touching, shaving, brushing teeth, blowing nose 4. encountering cold air from open car window

# Trigeminal Neuralgia what are 2 things that pts may try to do to avoid triggering?

1. rubbing the face/trigger area 2. hold face still while talking

# Trigeminal Neuralgia 3 components of the trigeminal nerve

* V1: opthalmic nerve * V2: maxillary nerve * V3: mandibular nerve

# Trigeminal Neuralgia describe associated pain | 6

1. severe, paroxysmal, lancinating 2. starts as sensation of electrical shocks in the affected area 3. crescendos in < 20s to excruciating discomfort 4. begins to fade within seconds and leaves a burning ache 5. pain fully abates between attacks even if they are severe/frequent 6. may cause grimace, wince, or aversive head movement

# Trigeminal Neuralgia tx

* AEDs (carbamazepine or oxcarbazepine) * Gabapentin * Lamotrigine

# Trigeminal Neuralgia describe AEDs for tx

* inhibit neuronal sodium channel activity, reducing excitability of neurons

# Trigeminal Neuralgia describe gabapentin for tx

* modulation of excitatory transmitters involved in pain

# Trigeminal Neuralgia describe lamotrigine for tx

* inhibits release of glutamate (excitatory amino acid) and inhibits neuronal sodium channel activity which stabilizes neuronal membranes, reducing excitability

# Trigeminal Neuralgia surgical tx

* microvascular decompression * Gamma knife tx * Radiofrequency

# Trigeminal Neuralgia what does gamma knife tx do?

damages trigeminal nerve to stop transmission of pain signals

# Trigeminal Neuralgia what does radiofrequency do?

damages trigeminal nerve to stop transmission of pain signals

# Trigeminal Neuralgia complications of surgery | 2

1. permanent anesthesia over face 2. disabling, spontaneous post-op pain (worse than original pain, untreatable)

# Trigeminal Neuralgia prognosis

* chronic * tx usually fail