ENT - Common Presentations

Question 1

Bell’s Palsy (Facial Nerve Palsy)

Pathophysiology
Differential Diagnosis
Clinical Features
Ramsey-Hunt Syndrome

Answer 1

1.) Pathophysiology - idiopathic weakness or paralysis of the muscles of the face
- risk factors: viral infection (HSV-1, CMV EBV), others include diabetes and pregnancy
- 85% of cases will recover, the majority make a full recovery with no evidence of residual symptoms.

2.) Differential Diagnosis
- UMN: stroke, subdural haematoma, brain tumour
- LMN: infective (AOM, cholesteatoma, viral infection), parotid malignancy, trauma or iatrogenic

3.) Clinical Features - painless unilateral LMN weakness of facial muscles of varying severities leading to:
- inability to close eye (temporal and zygomatic)
- reduced lacrimation (greater petrosal), metallic taste (chorda tympani), hyperacusis (nerve to stapedius)
- forehead sparing suggests UMN lesion
- may have some pain behind the ear (not Ramsey-Hunt syndrome)

4.) Ramsey-Hunt Syndrome - Herpes Zoster oticus, unilateral facial palsy caused by reactivation of varicella-zoster virus from the geniculate nucleus
- presents with mod-severe ear pain, developing into a facial palsy over a few days, other symptoms include:
- ipsilateral vertigo, hyperacusis, tinnitus, vesicles on the concha, anterior ⅔ tongue, and/or the soft palate
- treatment: PO prednisolone (5d) + PO acyclovir (7d)
- more severe than Bell’s, only 10% recover if untreated

Question 2

Assessment and Management of Bell’s Palsy

Investigations
Medical Management
Surgical Referral

Answer 2

1.) Investigations - often a clinical diagnosis
- diagnosis of exclusion so investigations involve exclusion of other causes of facial nerve palsy
- House-Brackmann classification is used to grade the severity of facial nerve palsy, grades 1-6
- viral serology: HSV-1, varicella-zoster virus

2.) Medical Management - steroids + aciclovir
- oral corticosteroids if presenting within 72hrs of sx
- 25mg BD for 10 days OR 60mg OD for 5 days
followed by a daily reduction in dose of 10 mg
- PO aciclovir anti-virals are often used but this is debatable
- use eye protection/tape the eye at night and apply artificial tears daily to prevent exposure keratopathy
- prognosis: most make a full recovery within 3-4 months, 15% can have permanent moderate to severe weakness if left untreated

3.) Surgical Referral
- refer to ENT: recurrent or bilateral Bell’s palsy, doubt over the diagnosis, no improvement after 3 weeks
- refer to ophthalmology: cornea remains exposed after attempting to close the eyelid (grade 4+)
- refer to plastic surgery: long-standing weakness e.g. several months
- surgical options: botox injections, anterior belly of digastric transfer, fascia lata sling, or cross-facial nerve grafting.