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A 67-year-old gentleman woke up with weakness on the right side of his face this morning. The whole right half of the face is weak. He was not able to close his right eye. He thinks that it all started yesterday evening. The angle of this right side of the mouth was dropped below the left side. He had some ache behind his right ear. When you ask him to close his eyes the right eye is slower and weaker. The pupil appears to ascend. He has a history of diabetes.
1. What is the diagnosis
This sound very much like Bell's palsy. A LMN weakness of the Facial nerve affecting the entire half of the face. Stroke and other conditions tend to leave the forehead and eye closure spared. . Facial nerve weakness in stroke rarely affects eye close as there is a bilateral cortical representation of the upper face. The lesion is within the facial canal. The face often feels numb (even though the facial nerve provides only motor as facial sensation is trigeminal) and weak.
The exact aetiology is unclear - it is likely due to latent reinfection with Herpes simplex virus but some may be due to herpes zoster. The inflamed nerve swells within the bony canal and function is impaired. Rare causes include sarcoidosis, middle ear disease, local tumour s, skull fracture, and Guillain-Barre syndrome and Lyme disease
2. What is the main concern
The main concern long term is a return of function to the facial nerve and a good cosmetic and functional recovery. Immediately the concern is protecting his eye from damage due to the fact that he cannot fully close his eye. If eye closure is not complete or indeed worsens the patient should wear glasses to reduce the drying effect of air and if that is possible and also cover the eye with gauze especially when sleeping and use artificial tears every few hours to keep the cornea hydrated. In all but the mildest cases a referral to ophthalmology would be wise.
3. Is there any treatment that can hep recovery
Trials have shown that high dose steroids for 7-10 days can improve outcome. Antivirals seem however to have little effect on Bell's palsy. Steroids are given if the patient presents within the first 72 hours. Most patients will have an improvement over the next 6-12 weeks and the benefits of steroids must be balanced with the side effects as rather high doses are given for 7-10 days. Steroids can worsen any diabetes.
4. The patient points out to you a rash in his right ear. You inspect and see some small vesicles. What does this signify
This suggests that the rash and infection of the nerve may be due to Herpes Zoster and in this case antivirals are also given and the patient is commenced on Oral Aciclovir. Antivirals are given in additional to steroids if diagnosis considered to be Ramsay Hunt syndrome.
5. What is this syndrome called
This is known as Ramsay Hunt Syndrome
6. The initial description said that his eye moved up on attempted eye close. What is this called
This is called Bell's sign. It is a classical sign of Bell's palsy.
7. A patient presents with Bilateral Facial nerve weakness (this is very very rare other than in exams) What are possible causes