Facial palsy, lumps in neck and salivary glands Flashcards
Where in the brain does the facial nerve arise?
rises in the medulla and emerges between the pons and the medulla
What are the intracranial causes of facial palsy?
Brainstem tumours Strokes polio MS acoustic neuroma meningitis
What are the intratemporal causes of facial palsy?
They are otitis media
Ramsay hunt syndrome (herpes zoster oticus)
Cholesteatoma
What are the infratemporal causes of facial palsy?
Parotid tumours
Trauma leading to complete palsy indicates urgent CT as surgical exploration may be required
How do you differentiate between an upper and lower motor neurone facial palsy?
In upper the forehead is spared because it is bilaterally innervated
What tests should be done for facial palsy?
Should do ESR, Glucose and lyme disease serology
examine the parotid for lumps
Ears to excluse cholesteatoma and ramsay hunt syndrome
Do MRI for space occupying lesions, cerebrovascular accident, MS, temporal bone fracture
How do you diagnose bells palsy?
This is an idiopathic palsy of the LMN and is partly a diagnosis of exclusion
What is the pathophysiology behind bells palsy?
Thought to be due to odema causing entrapment of the facial nerve in the narrow bony canal
How fast is the onset of idiopathic facial palsy?
Onset is abrupt (overnight)
What is the treatment of idiopathic facial palsy?
Prednisolone helps improve the rate of revovery
Help protect the eye with moistening drops
When should bells palsy be referred?
When it has lasted over 1 month
If there is recurrence
If there is doubt about the diagnosis
What is the prognosis for bells palsy?
Most have full recoery in 3 months (85%)
Some will have no recovery (5%) - refer to plastics if > 6 months
When diagnosing neck lumps what sort of time period requires investigation?
If the lump has been present for less than 3 weeks then it is likely to be a reactive lymphadenopathy and investigation is unwise
What tests should be done for a neck lump?
Should US lumps to guide fine needle aspiration
CT can help define masses in relation to their anatomical neighbours
Do virology and mantoux test (TB)
What can a chest x ray show in patinets with neck lumps?
Can show malignancy or bilateral hilar lymphadenopathy in sarcoid
What are possible differentials for midline lumps?
If the patient is <20 then it is likely a dermoid cyst
If it moves up on tongue potrusion then it is likely to be a thyroglossal cyst
If older than 20 then it could be a thyroid mass
What are the possible differentials for lumps in the submandibular triangle?
They could be self limiting reactive lymphadenopathy if <20
If greater than 20 need to exclude malignant lymphadenopathy - firm, non tender, weight loss, fever, night sweats
Is TB likely?
If it is not a node think submandibular salivary stone or tumour
What are differentials for lumps in the anterior triange?
Lymphadenopathy is common
Is the spleen enlarged with symptoms such as weight loss (lymphoma)
Branchial cysts - where upper third of SCM meets middle third - contain cholesterol crystals
If superoposterior could be parotid tumour
Pulsatile lumps:
-carotid aneurysm
-Tortuous carotid artery
-Carotid body tumour
What are the differentials for a lump in the posterior triangle of the neck?
Cervical ribs can intrude into this area, can cause neuro symptoms by compressing brachial plexus
Pharyngeal pouches can protrude into the posterior triangle on swallowing
Cystic hygromas are macrocystic lymphatic malformations - transilluminate brightly
Any small lumps think lymphadenopathy (TB or viruses) or metastases
What are the possible differentials if fine needle aspiration is positive?
SCC -MRI/CT Adenocarcinoma- MRI/CT Melanoma - skin cancer MDT Thyroid carcinoma - US thyroid Lymphoma - excision Merkel cell carcinoma - skin cancer MDT
How do you examine the salivary glands?
Look for any swellings, palpate for stones, test facial nerve function
Note the size, mobility and extend of any mass
What is Sialadenitis?
This is an acute infection of the submandibular or parotid glands, usually occurs in elderly dehydrated patients
What is the presentation of sialadenitis?
Painful diffuse swelling of the gland with fever
Pressure on the gland may lead to puss leaking out of the duct
What is the treatment of sialadenitis?
Treated with antibiotics and good oral hygiene
Sialogogues are helpful e.g. lemon drops that stimulate salivation
Surgical drainage may be required
Recurrent infection can occur with salivary duct stenosis
