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Culprit of Facial Nerve Palsy

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Culprit of Facial Nerve Palsy Original article Emerg Med J: first published as 10.1136/emermed-2019-208691 on 22 October 2019. Downloaded from Image CHALLENGE Culprit of facial nerve palsy CLINICAL INTRODUCTION A female patient aged 78 years with a medical history of hyper- tension, type 2 diabetes and dyslipidemia, presented with right otalgia. At her first consultation, amoxicillin and clavulanic acid and topical ofloxacin were prescribed after the suggestion of a bacterial infection process, but without improvement of the symptoms. She arrived at our ED 3 days later with an acute onset of impaired facial expression and ocular pain. On physical exam- ination, she was noted to have right conjunctival hyperemia, right-sided facial nerve palsy (VI degree on the House-Brack- mann scale) (figure 1) and a vesicular rash on the ipsilateral ear. The remaining neurological examination was normal. QUESTION What is the most likely cause for facial nerve palsy? A. Bell’s palsy Figure 1 Right-sided facial nerve palsy. copyright. B. Acoustic neuroma C. Ramsay Hunt syndrome (RHS) D. Stroke For answer see page 683 http://emj.bmj.com/ on November 8, 2019 by Anne Meneghetti. Protected Becker TK, et al. Emerg Med J 2019;36:660–665. doi:10.1136/emermed-2018-208234 665 Original article Emerg Med J: first published as 10.1136/emermed-2019-208691 on 22 October 2019. Downloaded from Image CHALLENGE Culprit of facial nerve palsy For question see page 665 ANSWER: C Initially, clinicians should focus on determining whether the patient has a peripheral or central cause for the facial nerve palsy.1 A central facial palsy due to a stroke spares the forehead. An acoustic neuroma can cause facial palsy but is more likely in patients who report hearing loss, tinnitus or have an unsteady gait.1 Compared with Bell's palsy, patients with RHS often have more severe paralysis at the onset and are less likely to recover copyright. completely.1 Since these two entities may initially be indistin- guishable, a meticulous physical examination should be made to look for a vesicular rash in the ear (figure 2), which corroborates the diagnosis of RHS. RHS is a rare complication of the reactivation of the latent varicella zoster virus in the geniculate ganglion. Its clinical presentation varies according to the number and extent of the http://emj.bmj.com/ impairment of the cranial nerves.2 Classically, it is manifested by an erythematous vesicular rash of the ear canal skin and auricle, otalgia and ipsilateral peripheral facial paralysis.2 3 It can also occur with ipsilateral palate alteration, lesions on the tongue; hearing impairment (deafness, tinnitus, hyperacusis); lacrimation and vertigo.3 The treatment is controversial, but corticosteroid therapy combined with an antiviral seems to allow a significantly on November 8, 2019 by Anne Meneghetti. Protected higher recovery rate than corticosteroids alone.1 Mónica Martins Teixeira , Rita Soares, Nuno Monteiro Figure 2 Erythematous vesicular rash of the ear canal. Department of Internal Medicine, Centro Hospitalar Tondela-Viseu EPE, Viseu, Portugal To cite Teixeira MM, Soares R, Monteiro N. Emerg Med J 2019;36:683. Correspondence to Dr. Mónica Martins Teixeira, Department of Internal Medicine, Accepted 5 May 2019 Centro Hospitalar Tondela-Viseu EPE, Viseu 3509-504, Portugal; Emerg Med J 2019;36:683. monicamteixeira. 9@ gmail. com doi:10.1136/emermed-2019-208691 Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. ORCID iD Mónica Martins Teixeira http:// orcid. org/ 0000- 0002- 7179- 7542 Competing interests None declared. Patient consent for publication Obtained. REFERENCES Provenance and peer review Not commissioned; internally peer reviewed. 1 Garro A, Nigrovic LE. Managing Peripheral Facial Palsy. Ann Emerg Med 2018;71:618–24. 2 Adour KK. Otological complications of herpes zoster. Ann Neurol 1994;35:S62–4. © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and 3 Shin DH, Kim BR, Shin JE, et al. Clinical manifestations in patients with herpes zoster permissions. Published by BMJ. oticus. Eur Arch Otorhinolaryngol 2016;273:1739–43. Garner AA, et al. Emerg Med J 2019;36:678–683. doi:10.1136/emermed-2019-208421 683.
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