A 48-year-old man comes to the emergency department due to facial drooping. The patient says he had mild left ear discomfort in the morning, and he had difficulty closing the left eye to the sunlight while driving to work. Four hours later, he was unable to sip drinks through a straw, and a colleague remarked that his face appeared droopy. He has had no upper or lower limb weakness or numbness, headache, fever, dizziness, or hearing loss. The patient was recently diagnosed with hypertension and hyperlipidemia, which he is managing with lifestyle modification. He smokes cigarettes and drinks alcohol daily and says he is trying to cut down on both. Temperature is 37 C (98.6 F), blood pressure is 142/86 mm Hg, and pulse is 84/min. On physical examination, there is left facial asymmetry with drooping of the left corner of the mouth and flattening of the nasolabial fold. He is unable to fully close the left eye. Extraocular movements are intact, and pupils are briskly reactive. Bilateral hand grips are equal, and there is no pronator drift. The patient is able to lift his lower extremities against resistance, and gait is normal. Sensation to light touch and pain is intact on the left side of the face. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 48-year-old man comes to the emergency department due to facial drooping.  The patient says he had mild left ear discomfort in the morning, and he had difficulty closing the left eye to the sunlight while driving to work.  Four hours later, he was unable to sip drinks through a straw, and a colleague remarked that his face appeared droopy.  He has had no upper or lower limb weakness or numbness, headache, fever, dizziness, or hearing loss.  The patient was recently diagnosed with hypertension and hyperlipidemia, which he is managing with lifestyle modification.  He smokes cigarettes and drinks alcohol daily and says he is trying to cut down on both.  Temperature is 37 C (98.6 F), blood pressure is 142/86 mm Hg, and pulse is 84/min.  On physical examination, there is left facial asymmetry with drooping of the left corner of the mouth and flattening of the nasolabial fold.  He is unable to fully close the left eye.  Extraocular movements are intact, and pupils are briskly reactive.  Bilateral hand grips are equal, and there is no pronator drift.  The patient is able to lift his lower extremities against resistance, and gait is normal.  Sensation to light touch and pain is intact on the left side of the face.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d143_0539_bc81_79cd5ce44e31_MD0003_00 This patient with acute-onset, unilateral facial drooping involving the upper and lower face likely has Bell palsy, a peripheral neuropathy involving the facial nerve (CN VII). Symptom onset is typically acute (over the course of hours) and progressive, with maximal weakness occurring within 3 weeks. It may be preceded by a prodrome of auricular pain or dysacusis (distortion of sound). Unilateral facial paralysis is characterized by mouth drooping, disappearance of the nasolabial fold, and, most importantly, involvement of the upper face (eg, inability to close the eye, weakness raising the eyebrow), which helps distinguish Bell palsy from acute stroke (in which the upper face is typically spared). Patients with Bell palsy may also have decreased tearing, hyperacusis, and a reduced sense of taste over the anterior two-thirds of the tongue. Sensation is typically intact. upper face The mainstay of therapy is high-dose oral glucocorticoids (eg, prednisone), which should be started within 72 hours of symptom onset. Because many cases are thought to be caused by reactivation of the herpes simplex virus, some studies also suggest the addition of valacyclovir or acyclovir. Patients with incomplete eye closure should also be counseled on corneal protection strategies (eg, moisture chamber, lubricating drops or ointment, taping the eye closed at night). Most patients improve spontaneously within 3-4 months; palsies lasting longer suggest another diagnosis. (Choices A and B) Alteplase is indicated for reperfusion therapy in select patients who arrive within 4.5 hours after an acute ischemic stroke, whereas aspirin and statins are indicated for patients outside this window (and for long-term therapy). Although stroke can cause facial weakness, it typically does not involve the eye or forehead. It may also be associated with facial numbness, dysphagia, or weakness in the limbs. (Choice C) Carbamazepine is used to treat trigeminal neuralgia, which causes paroxysms of severe, unilateral, stabbing pain in a branch of the trigeminal nerve. It is not associated with facial weakness. (Choice D) Ganciclovir is used to treat cytomegalovirus infections, which are not typically associated with the development of Bell palsy. It is not recommended for use in combination with glucocorticoids for Bell palsy. Educational objective: Bell palsy (CN VII peripheral neuropathy) presents with acute, progressive, unilateral facial weakness involving the upper and lower face. A prodrome of auricular pain may be present. Therapy is with glucocorticoids, possibly in combination with acyclovir or valacyclovir.

A 48-Year-Old Man Comes to the Emergency Department Due to Facial