HI

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?

great hi

so what about the causes of bell's palsy first. did they look in his ear?

ok back up a bit, do you know how it started?

ok but did he have any ear pain, did he have any viral symptoms prior to that?

cold, sinusitis, the flu?

ok so maybe a virus, but he needs to be checked for diabetes, lyme disease, any chance of lupus in the family?

and his ear, looking for something called Ramsay-Hunt syndrome which is a type of viral disease of the ear canal

do you have lyme in your area?

right no lyme, coccidiomycosis is a cause in AZ, although rare

but he has no lung symptoms correct?

or skin lesions

great

so the only other thing is did they do a CT of the brain to exclude an acoustic neuroma?

right

absolutely, anything autoimmune, a reaction to a spider bite, or snake bite..... rattle snake?

and there is no history of neurofibromatosis type 1 or 2 ( multiple familial diseases with neurofibromas/acoustic neuromas, skin lesions (cafe au lait macules))

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

unlikely.

did he have a chronic form?

or was it exposure to a virus, and then 4 to6 wweeks all better???

fine

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??

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.

the neurologist could at a later date do an emg to look at if the nerve is working well enough

facial nerve conduction study

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?

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?

with a loss of taste, that really puts the lesion in the nerve

and the facial pain and swelling??

a central lesion (brain or brainstem) would involve only 2

parts of the facial strength

and a peripheral nerve lesion is all 3 parts.

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

what other questions do you have? you should start warm oil massage on the face

around the parotid gland

absolutely, there is no neurological intervention if this is a stable bell's palsy

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

anything else?

yes

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

no problem come back anytime if you note something has changed and you want to talk about it ok?

if you are satisfied with this answer, please rate me as that is how I am compensated thank you Dr Frank T.

you are welcome

bye

oh, you can print this by right clicking on the next part ok??