Physical Exam
Clinical Exam Findings of Facial Nerve Palsy
Intelligent Dental. (n.d.). Intelligent Dental. Retrieved August 6, 2014, from http://www.intelligentdental.com/2011/11/29/bells-palsy-part-1/
- T: 97.6 HR: 66 BP: 112/68 RR: 14
- Left facial drooping
- Decreased forehead crease
- Decreased ability to smile
- Decreased blinking on left side
- Inflammation and erythema of left outer ear canal
- Raised, non-pruritic, erythematous rash of abdomen, thigh, and buttocks
Physical Exam Cont'd
- Recent and remote memory intact
- Oriented to person, place, time
- Motor 5/5 bilaterally
- Speech is clear and appropriate
Multiple Rashes on Abdomen, Thighs, and Buttocks
Koven, S. (2013, August 14). In Practice: Nothing Simple About Lyme. Boston.com. Retrieved August 3, 2014, from http://www.boston.com
Abstract
The differential for facial nerve etiologies is vast. Classically unilateral facial nerve paralysis is thought to be associated with Bell's Palsy which is typically considered idiopathic in nature, but there may be links to HSV-1 as a the source of inflammation. A patient's history and physical is essential in making an accurate diagnosis. In the case of Lyme-associated FNP, it is especially important to consider the likelihood of contracting the disease--history of tick bites, being outdoors, living in an endemic area. In addition, the classic erythema migrans rash is found in nearly 80-90% of patients with Lyme disease. The presence of erythema migrans is diagnostic, but further laboratory tests including Lyme titer and Western Blot should be considered. Treatment includes doxycycline. The use of prednisone may be considered. Prognosis is good with greater than 90% of patients achieving near or full recovery with no sequelae.
Pathophysiology
Case
Differentiating CNS from PNS lesions
Tiemstra, J., & Khatkhate, N. (2007). Bell's Palsy: Diagnosis and Management. American Family Physician, 76(7), 997-1002.
- Infection by Borrelia burgdorferi causes inflammation and loss of function in CN 7
- Resulting in unilateral findings:
- Weakness of facial muscles
- Mouth and eye droop
- Inability to close eye
- Inability to furrow brow
- Possible loss of taste
Return Office Visit
- 56 yo male
- PMH: Asthma and GERD
- CC:
- Left facial drooping x 3 days
- Multiple non-pruritic skin rashes on stomach, thigh, buttocks x 3 days
- H/O HA, arthralgias, and fever of 102.8 F, 9 days ago
- Erythematous welt under Left eye
- Left ear pain, mastoid process
- Avid outdoorsman, H/O tick bites in the past
- Was seen in the office 5 days later
- Persistent Facial Nerve Palsy
- Erythema migrans rash had nearly resolved
- Lyme titer and Western Blot were reviewed with patient
- Current treatment was maintained (Doxycycline and tapering Steroid Dose)
Etiology
- Inflammation of cranial nerve 7
- Compression, ischemia, and demyelination of the facial canal
- This causes a paralysis in the facial nerve circuit not allowing signals to be passed between the central and peripheral nervous system
- Loss of facial nerve motor and sensory function ensues
Tiemstra, J., & Khatkhate, N. (2007). Bell's Palsy: Diagnosis and Management. American Family Physician, 76(7), 997-1002.
Lyme Disease-associated Facial Nerve Paralysis
August 8, 2014
Beth Sholder
References
Baugh, Reginald, Gregory Basura, Richard Gurgel, John Halperin, Ayesha Khalid, Kaparaboyna Kumar, Alan Micco, Debra Munsell, Steven Rosenbaum, William Vaughn, Lisa Ishii, Seth Schwartz, Caitlin Drumheller, Rebecca Burkholder, Nathan Deckard, Cindy Dawson, Colin Driscoll, and M. Boyd Gillespie. "Clinical Practice Guideline: Bell’s Palsy." American Academy of Otolaryngology- Head and Neck Surgery 149.3S (2013): S1-S27. Sage Publications. Web. 30 July 2014.
Dotevall, Leif, and Lars Hagberg. "Successful Oral Doxycycline Treatment of Lyme Disease‐Associated Facial Palsy and Meningitis." Clinical Infectious Diseases 28.3 (1999): 569-574. Print.
Halperin, J. J. (2008). Nervous System Lyme Disease. Infectious Disease Clinics of North America, 22(2), 261-274.
Intelligent Dental. (n.d.). Intelligent Dental. Retrieved August 6, 2014, from http://www.intelligentdental.com/2011/11/29/bells-palsy-part-1/
Koven, S. (2013, August 14). In Practice: Nothing Simple About Lyme. Boston.com. Retrieved August 3, 2014, from http://www.boston.com
"Lyme Disease." ClinicalKey - Smarter Search, Faster Answers for Doctors & Clinicians. Elsevier, Inc., n.d. Web. 6 Aug. 2014. <http://www.clinicalkey.com>.
Siwula, J., & Mathieu, G. (2002). Acute onset of facial nerve palsy associated with Lyme disease in a 6-year-old child. Pediatric Dentistry, 24(6), 572-574.
Tiemstra, J., & Khatkhate, N. (2007). Bell's Palsy: Diagnosis and Management. American Family Physician, 76(7), 997-1002.
Differential Diagnosis
- #1 Lyme Disease-associated Facial Nerve Palsy
- Bell's palsy
- Idiopathic
- Viral Etiology-HSV-1?
- Guillain-Barre Syndrome
- Ramsay-Hunt Syndrome
- Otitis Media
- Multiple Sclerosis
- Stroke
Classic Signs
and Symptoms
Standard Diagnostic Tests
- Signs:
- Fever
- Erythema migrans
- Conjunctival inflammation
- Joint swelling/tenderness
- Limited ROM especially larger joints
- Symptoms:
- Early
- HA, neck stiffness, arthralgias, low-grade fever, fatigue, lightheadedness
- Late
- Joint pain, focal weakness, parathesias, cognitive impairment
- Two-tier system for testing:
- ELISA or fluorescent antibody testing
- If positive or indeterminate a Western blot is used to detect Borrelia proteins of specific molecular sizes
Lab Tests
- WBC: 7.1
- RBC: 4.91
- HGB: 14.3
- HCT: 43.5
- ESR: 54
- Lyme Ab Test: > 5.00 (Positive >1.10)
- Western Blot (IgM): 3/3 bands were "reactive"
Standard Treatments
Conclusion
- Facial nerve palsy is commonly idiopathic or viral in nature.
- It is essential to rule out an upper motor lesion such as a stroke or brain tumor.
- Upper motor neuron lesions are forehead-sparing.
- A thorough history and physical is essential to diagnosis.
- Erythema migrans rash is diagnostic for lyme disease and treatment should begin even if the Lyme titer is pending.
- Treatment
- Doxycycline for those > 8 yo
- Amoxicillin or Pen G for those < 8yo
- Early Lyme Disease:
- Doxycycline:
- Adults and adolescents: 100 mg orally BID 10-21 days
- Children aged 8 yo+: 4 mg/kg/d orally in two divided doses, 10 to 21 days
- Facial Nerve Paralysis
- Corticosteroids have been recommended, but evidence is conflicting. Studies do not show clear help or harm
Empirical Treatment
and Diagnostics
Prognosis
- Due to clinical suspicion of Lyme disease patient was started on :
- 100 mg Doxycycline BID for 15 days
- Medrol Dose Pack, 4 mg, tapering dose
- CBC, BMP, ESR, Lyme Titer and Western Blot were ordered
- Prognosis is good with greater than 90% of those with Lyme-associated FNP regaining full or nearly-full function.
- Early treatment with doxycycline has a cure rate of greater than 90% in those with early Lyme Disease.
- Rarely some patients may experience residual effects due to the initial inflammatory reaction.