My friend started having numbness in the right side of his face yesterday morning. He is having slightly blurred vision in the right eye and decreased taste and sensation in his tongue. His tongue is midline. His face is slightly puffy on the right side. No headache or numbness/weakness anywhere else on his body. He went to the ER yesterday and they told him that he has Bells Palsy. They sent him home with a prescription for Prednisone and Acyclovir and instructed him to follow up with a neurologist in 3 days. He just started a new job and doesn't have insurance until July 23rd. What is your recommendation for his case? What will the neurologist do for him?
Person's Gender: Male
Person's Age: 30
Prednisone and Acyclovir
I will wait for you to come online
The only thing you did not mention in your evaluation of his diagnosis and care in the ER is if they evaluated him for the causes of bell's palsy. From the symptomatology, it does sound like he has a peripheral cranial nerve VII lesion starting
hi are you there?
thank you for your help
so what about the causes of bell's palsy first. did they look in his ear?
I know that they did a fairly basic neurological exam on him
They did do an ear exam
ok back up a bit, do you know how it started?
Well he said that he was having some decreased sensation on his tongue earlier in the day and that it progressed to where he was having difficulty putting his lips around a straw
then he started to get numbness on the right side of his face\
ok but did he have any ear pain, did he have any viral symptoms prior to that?
cold, sinusitis, the flu?
no ear pain, no HA, but slight blurry vision in the left eye
the only thing he said was that he was feeling more drained than usual
no current cold or flu symptoms otherwise
ok so maybe a virus, but he needs to be checked for diabetes, lyme disease, any chance of lupus in the family?
I'm not sure if they did a finger stick on him in the ER... I hope so.
and his ear, looking for something called Ramsay-Hunt syndrome which is a type of viral disease of the ear canal
I don't think any familial hx of lupus
do you have lyme in your area?
we live in AZ so it's possible but unlikely
right no lyme, coccidiomycosis is a cause in AZ, although rare
but he has no lung symptoms correct?
no SOB, no dizziness
or skin lesions
so the only other thing is did they do a CT of the brain to exclude an acoustic neuroma?
not that he is aware of so it doesn't seam to be an allergic rx to a bite of some sort
but it's possible I uppose
absolutely, anything autoimmune, a reaction to a spider bite, or snake bite..... rattle snake?
They didn't do a CT or MRI, they just called it Bells Palsy and then gave him a prescription for steroids and acyclovir
and there is no history of neurofibromatosis type 1 or 2 ( multiple familial diseases with neurofibromas/acoustic neuromas, skin lesions (cafe au lait macules))
not that I'm aware of...
His grandfather had guillain-barre. Could that be at all related?
theser are all rare causes, but we usually do a CT of the brain just for completeness sake, I really don't think a young man has to have one
did he have a chronic form?
It was fairly acute from what I understood
or was it exposure to a virus, and then 4 to6 wweeks all better???
so he has recieved the treatment for bells, you should just check that sugar.
acyclovir I give for 10 days
steroids are contraversial, I don't actually use them in a regular bells
based on risk/benefit
do you know if he notes that sounds are different from that ear??
What about following up with the neurologist? Do you think it can wait until July 23rd for his insurance or do you think that he should go as soon as possible?
He didn't mention any hearing changes
absolutely I would wait. the issue is that if you are not 15% improved at 3 months, you may not completely improve, but anything more than that you will improve.
if they didn't check his sugar and it is high the steroids are only going to increase the blood sugar levels too...
the neurologist could at a later date do an emg to look at if the nerve is working well enough
facial nerve conduction study
I'm familiar with EMG
yes, he has to figure out the sugar issue, my guess is that they did test him somehow, no blood, did they look at his urine?
I was just worried about whether or not they needed to do further analysis to rule out TIA
well he doesn't need an emg now, and maybe not later
well first of all is it a central or peripheral VIIth nerve lesion?
how would you determine that?
with a loss of taste, that really puts the lesion in the nerve
and the facial pain and swelling??
definitely decreased taste and slightly swollen right sided face
a central lesion (brain or brainstem) would involve only 2
parts of the facial strength
and a peripheral nerve lesion is all 3 parts.
well he is having difficulty closing his eye and moving his mouth on the right side
that is because the motor to your forehead is crossinnervated , so the test is to have him try to raise his eyebrow on the affected side. If he can raise his eyebrow, and he has a dense facial weakness in his cheek and jaw, then he could have a stroke
do you understand that gibberish?
so this really sounds peripheral
ok that makes sense
what other questions do you have? you should start warm oil massage on the face
so most likely if he went to a neurologist right now they would probably just advise him to continue the current prescriptions and follow up at a later date anyway
around the parotid gland
absolutely, there is no neurological intervention if this is a stable bell's palsy
however if the numbess/tingling travels elsewhere on the body seek medical attention more urgently
ok that all makes sense
the fact that he isn't getting the weird noises from his ear is good as it suggests a nerve lesion past the branch to the stapedius muscle in his ear, and the recovery prognosis is better
exactly correct, he should not have any more cranial nerve problems loss of smell, or double vision tongue weakess, a drooping palate....
no numbness on the arms or legs weakness of course
so loss of smell, or double vision tongue weakess, a drooping palate would be signs of something more serious to follow-up with correct?
you may note that if you ask him to tighten the muscle in his neck under his chin (the platysma muscle) that it may be weak, that is normal and part of the bell's
That you for your help! I really appreciate it. I didn't know a lot about Bells Palsy so it's helpful to get an expert opinion.
no problem come back anytime if you note something has changed and you want to talk about it ok?
ok thank you very much
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you are welcome
Absolutely I will, thanks!
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