A 46-year-old African American man comes to the physician with a "funny feeling" in his face that started yesterday. He has difficulty smiling and chewing on the right side of his mouth. Cigarette smoking has also been difficult because he is unable to "puff." He has "cold sores" every few months that correlate with stressful deadlines at his computer programming job. He smokes 1 pack of cigarettes daily. He lives in Arizona and has not traveled outside of the state in at least 3 years. Physical examination shows wrinkling of the left forehead with ipsilateral eyebrow elevation. He is unable to raise his right eyebrow, and his right forehead remains smooth. When the patient is asked to close his eyes, his right eye remains partially open. The right side of his mouth appears droopy. The remainder of his examination is normal. Which of the following is the best next step in management of this patient?

Question

A 46-year-old African American man comes to the physician with a "funny feeling" in his face that started yesterday.  He has difficulty smiling and chewing on the right side of his mouth.  Cigarette smoking has also been difficult because he is unable to "puff."  He has "cold sores" every few months that correlate with stressful deadlines at his computer programming job.  He smokes 1 pack of cigarettes daily.  He lives in Arizona and has not traveled outside of the state in at least 3 years.  Physical examination shows wrinkling of the left forehead with ipsilateral eyebrow elevation.  He is unable to raise his right eyebrow, and his right forehead remains smooth.  When the patient is asked to close his eyes, his right eye remains partially open.  The right side of his mouth appears droopy.  The remainder of his examination is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfe9_2247_8f63_4b72111ee624_MD0005_00 The rapid onset of unilateral upper and lower facial weakness is consistent with Bell's palsy, an idiopathic neuropathy of cranial nerve VII. Common findings of the afflicted side include inability to raise the eyebrow or close the eye, drooping of the mouth corner, and disappearance of the nasolabial fold. The "funny feeling" described by this patient is due to the perception of stiffness or pulling of the face to 1 side. It is very important that patients be assessed for symmetry by raising their eyebrows due to bilateral upper-motor-neuron innervation to the forehead. Forehead muscle sparing is suggestive of an intracranial lesion and would warrant brain imaging (Choice E) to evaluate for ischemia or tumors. No diagnostic workup is necessary unless the patient presents with bilateral facial palsy, lives or has traveled to a Lyme-endemic area, or has other concerning symptoms. If there is a history of travel to the northeast or upper midwestern United States, erythema migrans, or bilateral facial palsy, serum enzyme-linked immunosorbent assay testing (Choice D)should be obtained. This patient lives in an area with a low incidence of Lyme disease and has no other symptoms, making this test superfluous. Lyme-endemic area Corticosteroids are the treatment of choice for Bell's palsy. They should be started within 3 days to improve chances of complete recovery. Eye care is extremely important for patients with poor eyelid closure as the cornea is at risk of dryness and abrasions. Therefore, artificial tears and eye patching should be prescribed. Most patients recover within 1-6 months of onset. (Choice B) Although reactivation of herpes simplex virus is thought to cause most cases of Bell's palsy, clinical trials have failed to demonstrate any benefit of antiviral monotherapy. Data regarding combination glucocorticoid and antiviral therapy remain controversial. (Choice C) Although uncommon, bilateral facial palsy can also occur in sarcoidosis. Chest x-ray should be performed if there is a high suspicion for sarcoidosis as almost all patients have lung involvement that classically presents as bilateral hilar adenopathy. However, this patient has no cough, dyspnea, or chest pain that typically occurs in sarcoidosis and should not undergo unnecessary radiation. Educational objective: Unilateral upper and lower facial weakness is consistent with cranial nerve VII neuropathy. No further workup is warranted unless the patient has traveled to a Lyme-endemic area or presents with other concerning symptoms. Corticosteroids and supportive eye care are the mainstays of treatment. References: Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/19724046) Ophthalmic management of facial nerve palsy: a review. (http://www.ncbi.nlm.nih.gov/pubmed/17355853) Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. (http://www.ncbi.nlm.nih.gov/pubmed/18849193) Early treatment with prednisolone or acyclovir in Bell's palsy. (http://www.ncbi.nlm.nih.gov/pubmed/17942873)

A 46-Year-Old African American Man Comes to the Physician with a "Funny