A 45-year-old woman from Texas comes to the physician with sudden onset of left-sided facial drooping. She first noticed the facial droop while eating Christmas dinner with her family last night. She has also experienced mild drooling from the left side of her mouth. She has no other complaints. The patient has no recent illnesses, travel, rashes, or tick bites. Her other medical problems include hypertension and mild obesity. Her medications include lisinopril and chlorthalidone.
Temperature is 36.5 C (97.7 F), blood pressure is 138/85 mm Hg, and pulse is 72/min. The patient has facial asymmetry, drooping of the left angle of her mouth, and loss of the left nasolabial fold. She is unable to close her left eyelid fully, wrinkle her forehead or nose, inflate her left cheek, or show her teeth. The remainder of the examination is within normal limits.
Which of the following is the best next step in management of this patient?

Question

A 45-year-old woman from Texas comes to the physician with sudden onset of left-sided facial drooping.  She first noticed the facial droop while eating Christmas dinner with her family last night.  She has also experienced mild drooling from the left side of her mouth.  She has no other complaints.  The patient has no recent illnesses, travel, rashes, or tick bites.  Her other medical problems include hypertension and mild obesity.  Her medications include lisinopril and chlorthalidone.
Temperature is 36.5 C (97.7 F), blood pressure is 138/85 mm Hg, and pulse is 72/min.  The patient has facial asymmetry, drooping of the left angle of her mouth, and loss of the left nasolabial fold.  She is unable to close her left eyelid fully, wrinkle her forehead or nose, inflate her left cheek, or show her teeth.  The remainder of the examination is within normal limits.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation is consistent with Bell's palsy, an acute peripheral facial nerve paralysis likely due to herpes simplex virus activation in most cases. The differential diagnoses for Bell's palsy include infections (eg, HIV, Lyme disease), space-occupying lesions (eg, sarcoid, tumor, cholesteatoma), and Sjögren syndrome. This patient's sudden onset without other associated symptoms makes Bell's palsy most likely. Nearly 70%-85% of patients recover within 3 weeks, but many studies suggest that prednisone given within 3 days of symptom onset significantly improves recovery. Some studies also suggest that adding valacyclovir may help patients with severe facial paralysis. (Choice B) Electromyography is used to monitor the progression of symptoms. However, it is usually performed days to weeks after symptom onset in patients without improvement to document complete facial paresis and determine chances of recovery. (Choice C) Lumbar puncture may help diagnose meningitis or encephalitis. However, this patient's normal mental status and lack of fever, headache, or nuchal rigidity make these diagnoses less likely. (Choice D) Disseminated Lyme disease may present with facial nerve palsy but usually has other associated features (eg, meningitis, radiculopathy, arthralgias). In addition, Lyme disease occurs more commonly in the upper Midwest and northeastern regions of the United States (eg, Connecticut) instead of Texas. Lyme disease is also more common in the summer months, not in winter. Routine testing for Lyme serologies is not recommended in patients with low possibility of exposure and who lack other clinical features of Lyme disease. (Choice E) Head MRI is indicated in patients with atypical symptoms/signs, facial twitching or spasm preceding weakness (suggests malignancy), slow progression of symptoms after 3 weeks, or no symptom improvement after 4 months. This patient has a classic presentation without facial spasm and does not need MRI at this time. Educational objective: Bell's palsy is an acute peripheral facial nerve palsy likely due to herpes simplex virus activation. Prednisone given early after symptom onset speeds recovery and enhances outcome. Addition of valacyclovir may help patients with severe facial palsy. __________ References: Early treatment with prednisolone or acyclovir in Bell's palsy. (http://www.ncbi.nlm.nih.gov/pubmed/17942873) Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter randomized placebo controlled study. (http://www.ncbi.nlm.nih.gov/pubmed/17414047)

A 45-Year-Old Woman from Texas Comes to the Physician with Sudden