Neurology - 1A and 1B

Question 1

What is Bells palsy?

What are the risk factors?

Answer 1

• Acute unilateral facial nerve weakness or paralysis of rapid onset <72 hours w unknown cause.
• HSV, VZV, autoimmunity –> contribute to development of bells palsy
• Rf –> age 15-45, previous stroke, brain tumour

Question 2

What is the typical presentation of bells palsy?

Answer 2

• Rapid onset <72 hours
• Facial muscle weakness –> upper and lower. Reduction in movement of affected side, dropping eyebrow, corner of mouth and loss nasolabial fold.
• Ear and post auricular region pain.
• Difficulty chewing, change in taste, dry mouth
• Incomplete eye closure, dry eyes, pain
• Numbness and tingling in cheek/mouth
• Speech articulation problems, drooling
• Hyperacusis

Question 3

What might you find on examination in bells palsy?

What are the differential diagnosis?

Answer 3

Focused –> scalp, ears, eyes, parotid glands, CN.

• Eyes can’t close –> close eyes, show teeth –> eyelid rotates upwards and outwards –> Bells phenomenon.
• Unable to blow cheeks, purse lips, whistle

DD- > stroke (forehead sparing), brain tumour (mental state changes), MS, facial nerve tumour, traumatic injury

Question 4

What are the investigations in bells palsy?

Answer 4

-Routine tests and diagnostic imaging not required in primary care for new onset bells palsy.

Question 5

What is the management for bells palsy?

When should you refer to a specialist?

Answer 5

Medical –> present in <72 hours onset –> prednisolone –> 50mg daily 10 days OR 60mg daily for 5 days then decrease by 10mg for 5 days.
-Conservative –> reassure most people make recovery within 3 to 4 months. Advise keep affected eye lubricated, eye drops, ointment at night. Tape close at night w microporous tape and if ability to close ey impaired. Antiviral not routinely recommended.

• Refer CN7 specialist –> when doubt or no improvement within 3 weeks, incomplete recovery in 3 months after onset or atypical features.
• Refer to ophthalmologist –> eye symptoms e.g pain, irritation
• Urgent referral –> worsening of existing neurological findings. Features suggest CNS cause. ?cancer, trauma, systemic or severe local infection

Question 6

What is essential tremor?

When is the typical onset and risk factors?

Answer 6

• Pathophysiology not clear, possible due to excess GABA
• Bimodal onset –> early adulthood and >60. 50% FH
• One of most common movement disorders
• Postural and action tremor
• RF –> increasing age, FH, toxin exposure

Question 7

What is the presentation of an essential tremor?

What are the differential diagnosis?

Answer 7

• Bilateral and symmetrical 7-12Hz tremor. Typically involves head and neck and hands and forearms –> sometimes w slight asymmetry.
• Tremor persistent and progressive
• Postural –> worse arms outstretched. Kinetic –> worse w movement e.g dressing
• Can worsen w stress, caffeine, sleep deprivation
• Tremor improve w alcohol
• No associated neuro deficits or signs.

DD –> thyrotoxicosis, med SE, alcohol, anxiety, parkinsons.

Question 8

What are the investigations for essential tremor?

Answer 8

• Bloods –> UandE, LFT, TFT, drug screen, 24 hour urine copper –> r/o thyroid and wilsons.
• Head CT/MRI ?

Question 9

What is the management for an essential tremor?

1st line and 2nd line

Answer 9

• 1st line –> BB propanolol (start low and titrate max 40mg BD), primidone (start 50mg ON, up to 250mg TDS).
• 2nd line –> Can combine propanolol and primidone. GABApentin, topiramate
• Conservative –> appropiate when symptoms don’t cause embarrassment or significant dysfunction
• No cure, ¼ on mdeication change job or retire early
• Refractory symptoms –> refer to neurologist to consider deep brain stimulation