Head and Facial Disorders Flashcards
Etiologies of facial palsy
Infectious Traumatic Tumor Cerebrovascular disease Toxin exposure Idiopathic (HSV goes here)
Risk for Bell’s palsy
Pregnancy (3x-increases during 3rd trimester and immediately postpartum)
Diabetes
Differential diagnosis of Bell’s palsy: Herpes zoster
Ramsay hunt syndrome (cephalic zoster with facial nerve involvement)
Vesicles near external meatus and ask about perherpetic neuralgia
Differential diagnosis of Bell’s palsy: otitis media
Possible complication
Differential diagnosis of Bell’s palsy: Lyme disease
Unilateral but typically BILATERAL lasting less than2 mos (maybe with lyme meningitis)
Eval in young pt and other associated sxs including erythema/swelling prior to palsy
Differential diagnosis of Bell’s palsy: Guillain Barre
Progressive, symmetric and bilateral
Differential diagnosis of Bell’s palsy: tumor
Gradual onset over 2+ weeks
Differential diagnosis of Bell’s palsy: stroke (central lesion)
Stroke spares forehead-upper motor neuron (rare for stroke to affect ipsilateral facial nerve nucleus or tracT)
What to think of with central facial palsy?
UMN lesion affects contralateral portion of lower face, forehead spared
Think STROKE, TUMOR, multiple sclerosis or trauma to motor cortex or corticobulbar tracts
What to think of with peripheral facial palsy?
LMN lesion affecting ipsilateral face (involves forehead)
Think of BELLS PALSY, Guillain Barre, otitis mesia, Lyme, Ramsay hunt syndrome
Still need to consider stroke and tumor tho
How to diagnose Bell’s palsy
Clinically
Diffuse facial nerve involvement
Acute onset in 1-2 days (progressive with max severity within 3 wks and improvement or recovery in 6 mos)
When to do diagnostic studies with Bell’s palsy?
Atypical sxs, no significant improvement in 4 mos or progression beyond 3 wks
What are the possible diagnostics that can be used with Bell’s palsy?
Electromyograph/nerve conduction study
CT/MRI
Labs (serological testing for lyme or HSV, fasting blood sugars in pts with risk factors of DM)
Mild cases of Bell’s palsy
May resolve spontaneously within 2 wks
Pharmacologic tx for Bell’s palsy
ALL pts!!!
Prednisone 60 mg daily x 5 days then taper by 10 mg daily x 5 days OR 60-80 mg daily x 7 days
Maybe valacyclovir 1g TID x 7 days
When do you see best results with pharmacologic tx of bells palsy?
If initiated within 3 days of sx onset
What to remember with eyes and Bells palsy
Increased risk of drying, corneal abrasion and corneal ulceration
Eye care for Bell’s palsy
Artificial tears (liquid or gel preps) applied hourly Eye ointmes (mineral oral and petrolatum) at night and maybe patch Sunglasses
Prognosis of Bell’s palsy
Most improve in 3 wks (normal function returning in 3-6 mos)
If complete paralysis only 60% return to normal
If incomplete 94% return to normal
What might be seen with new axon growth in Bell’s palsy?
Disorganized/synkinesis- blinking causes twitch in corner of mouth or smiling causes eye to wink
What is trigeminal neuralgia?
Recurrent brief episodes of severe, unilateral pain along 5th CN (one or more branches of TN may be triggered)
How is pain with trigeminal neuralgia?
Like electrical shock-like sensation
Incidence of trigeminal neuralgia
Increased with age, >50 YO
Women
Different classifications of trigeminal neuralgia
Classic: idiopathic or vascular compression of trigeminal nerve root
Painful trigeminal neuropathy (secondary trigeminal neuropathy): other causes like herpes zoster, vestibular schwannoma, meningioma, cyst, LS
Presentation of trigeminal neuralgia
Paroxyms of shooting pain lasting a few seconds and may occur repetitively (frequency varies, episodes of remission lasts for 6+ mos, recurrence if more frequent and disabling)
Usually unilateral presentation (most often V2 or V3)
What kinds of sxs may be seen with trigeminal neuralgia if V1 is affected?
Autonomic
Trigger zones with trigeminal neuralgia
Light touch may trigger an attack (pt guarding, chewing/ talking/shaving/brushing teeth)
What is pretrigeminal neuralgia?
Continous, dull ache in jaw prior to classic sxs present (rule out dental causes)
Diagnosis of trigeminal neuralgia due to international classification of HA disorders
At least 3 paroxysmal episodes of unilateral facial attacks (severe intensity, shock like shooting quality)
Affects trigeminal nerve distribution only
No neuro deficits
What imaging if think secondary cause for trigeminal neuralgia?
MRI with and without contrast preferred
Pharmacologic tx for trigeminal neuralgia
Carbamazepine (100 mg-200 mg BID): increase gradually with typical maintenance dose of 600 mg-800 mg total daily
Other anticonvulsant meds if can’t tolerate (oxycarbazepine, gabapentin, phenytoin)
Baclofen
SE of carbamazepine
Drowsiness, dizziness, n/v, leukopenia and rarely aplastic anemia
Labs needs for carbamazepine
Follow CBC routinely (HLA b1502 screening b/c increased risk for SJS)
Other management for trigeminal neuralgia
Botox, glycerol, radiofrequency thermal lesioning
Surgery (refractory to meds): microvascular decompression, ablation like rhizotomy and gamma knife radiosurgery
What is giant cell (temporal) arteritis?
Chronic vasculitis of medium and large vessels (diffuse inflammatory cells leading to wall thickening and decreased lumen)
Arteries that might be affected in giant cell (temporal) arteritis
Ophthalmic artery occlusion: blindness
Basilar artery occlusion: brain stem infarct
Incidence with giant cell arteritis
Increases with age (>50 YO and avg age 77)
Scandinavian descent
Some have polymyalgia rheumatica
Females
Possible presenting sxs of giant cell (temporal) arteritis
New HA (extracranial vessel involvement-unilateral severe HA with throbbing sensation and aggravated by pressure or cold exposure)
Visual disturbances: diplopia or transient blindness (amaurosis fugax)
Sxs with polymyalgia rheumatica
Jaw claudication is pathognomic
Unexplained fever or other constitutional sxs (fever, fatigue, weight loss)
PE for giant cell (temporal) arteritis
Vision eval
Tender, palpable temporal artery (pulse is decreased or absent, auscultate for bruits)
Muscle tenderness in neck and shoulders
Check for carotid bruits
Labs for giant cell (temporal) arteritis
Anemia maybe
ESR is most USEFUL screening tool (>50 mm/hr is 95%)
CRP elevation
Temporal artery biopsy with giant cell (temporal) arteritis
Minimum of 1-2 cm section of artery (skip lesions)
Presence of multi nucleated cells is diagnostic
American college of rheumatology diagnostic criteria for giant cell (temporal) arteritis
3/5 needed: Age on onset>50 YO New, localized HA Temporal artery tenderness, decreased temporal pulse ESR>50 mm/hr Positive temporal artery biopsy
Management goal of giant cell (temporal) arteritis
Prevent blindness or stroke
Management of giant cell (temporal) arteritis
Promptly initiate glucocorticoid tx (prednisone 40-60 mg daily and taper in 2-4 wks but continue with 10-20 mg faily for 9-12 mos)
If recurs then may need lifelong steroids
Follow ESR/CRP
What is temporomandibular joint dysfunction?
Pain associated with TMJ misalignment
Muscular hypertrophy with malocclusion
Arthritis: degeneration of articular surface
High risk of TMJ
Rheumatoid arthritis
What might be associated with TMJ?
20-40 YO
Bruxism, gum chewing, pencil biting, pipe smoking, musical instruments involving repetitive jaw motions, trauma, mood and psych disorders
Presentation of TMJ
Periauricular pain and tenderness of TMJ and muscles of mastication (HA or ear discomfort, radiate to ear/ temporal/periorbital regions)
Crepitus with movement (clicking or popping)
PE for TMJ
Subluxation and dislocation of jaw (catching vs locking)
Decreased ROM (demonstrate asymmetric opening and closing-malocclusion)
Abnormal dental wear
How to diagnose TMJ
Clinical
Other diagnostics for TMJ
Plain films: evaluate erosions, osteophytes, arthritis
CT?MRI: extreme pain, abnormal radiographs, changes in cranial nerves, previous surgery to TMJ
Management of TMJ
Dental referral PRN
Heat
Soft diet, avoiding repetitive chewing (gum)
Jaw exercises
Oral appliances (occlusal splints) may be beneficial
Pharm therapy for TMJ
Chronic pain- tylenol, NSAIDs, muscle relaxants
