Case Presentation

by Michael Armstrong

Chief Complaint
My face is numb on the right side, my

vision is blurry, and I cant close my

right eye.

History of present illness

Patient is a 39 y/o Hispanic female

with a 2 day complaint of numbness to

the right side of her face following an
aching pain in the right posterior
auricular space. The numbness has
progressed to the point where the
patient has blurred vision and can no
longer close her right eye.

HPI cont.
The patient states her right eye tears a

lot and she drools from the right side of

her mouth. She also admits to having
difficulty eating and drinking even
with a straw. She states Motrin has
helped with the pain. She denies
weakness to her extremities, loss of
consciousness, or head trauma.

Past Medical History

Hypothyroidism
Sarciodosis

Medications
Synthroid

Allergies
NKDA
NKFA

Vital Signs
BP

166/102
HR
84
RR
16
Temp 98.0
Ht
68 inches
Wt
204 lbs

Physical Exam
Gen: Pt. A/O x 3 w/ Rt. side facial droop
HEENT: NC/AT, PERRLA, + red reflex b/l,
EOM intact, ptosis of rt. eye, + light reflex
b/l, disc margins sharp, no A-V nicking,
TMs and canals clr., good acuity b/l, nares
patent, septum midline, MMM&P, pharynx
clr., MMM&P, throat supple, trachea
midline, no lymphadenopathy.

Physical Exam
Thorax: Symmetrical w/ equal expansion,
breath sounds vesicular and CTA b/l.
CVA: Normal S1,S2 w/ no murmurs, rubs,
or gallops. No JVD.
EXT: No edema. Good pulses x 4 extrem.

Neurological

Mental Status: Alert and oriented

Cranial Nerves: I VI intact
VII rt. side sens/mtr deficit
VIII XII intact
Motor: Strength 5/5 throughout. Gait normal.
Sensory: Romberg neg., pinprick, light touch,
position, vibration, and stereognosis intact.
Reflexes: Bi, tri, sup, abd, knee, ankle, & pl 2+

R/O Bells Palsy

CT of the head
Lyme titers

Differential Diagnosis
TIA
Ramsay Hunt Syndrome
Acoustic Neuromas
Heerfordts Syndrome
Melkersson-Rosenthal Syndrome

Bells Palsy
Described by Sir Charles Bell in the

19th century.
Idiopathic form of facial paralysis
resulting from inflammation of the
facial nerve.

Epidemiology
40,000 to 50,000 Americans annually.
May occur at any age.
More common amongst pregnant

women and those suffering from

diabetes, influenza, common cold, or
some other upper respiratory ailment.
Occurs more often in spring or fall.

Pathophysiology
Etiology unknown
Some research leans towards herpes

virus as a cause
Sarcoidosis and Lymes Disease also
potential causes

Signs and Symptoms

Unilateral facial
paralysis
Inability to close
the eye
Absence of the
nasolabial fold
May be loss of taste
on anterior tongue

Pain behind the ear

Tearing
Drooling
Hyperacusis
Sag of the eyebrow

Diagnosis
Based on clinical findings
Imaging studies used to rule out other

pathology
Lyme titers, PCR testing may indicate
cause

Treatment
Corticosteroids (efficacy not proven)
Analgesics
Lubricating eye drops
Taping eye closed at night
Massage of the weakened muscles

Prognosis
Generally very good
Most patients get significantly better in

about 2 weeks even without treatment

80-85% recover completely within 3
months
10% have permanent disfigurement or
other long term sequelae

References
National Institute of Neurological Disorders
and Stroke (online)
National Institute of Dental and
Craniofacial Research (online)
Merck Manual (online)
Harrisons Principals of Internal Medicine