The list of medical tests
mentioned in various sources as
used in the diagnosis of Bell's Palsy
includes:
Immediate referral to a neurologist is indicated. One should do a complete examination of the ear, nose, and throat to determine if there is any rupture of the drum, discharge, evidence of otitis media, etc. Then x-rays of the mastoids and petrous bones should be done along with tomography. A CT scan of the brain with emphasis on the internal auditory foramina should be done if acoustic neuroma is suspected. Culture of the discharge from the ears and blood culture should be done if there are associated signs of an infectious process. Testing for Lyme disease may be indicated. Spinal fluid analysis should be done to look for Guillain-Barré syndrome. If myasthenia gravis is suspected, a Tensilon test may be done. Spinal fluid culture should be done in cases of brain abscess. Carotid scans and a workup for an embolic source should be done in cases of cerebral vascular accident. Of course, when there is a brain tumor or abscess or a cerebral vascular accident is suspected, CT scans of the brain should be done. If these are not helpful or are inconclusive, MRI of the brain can be done. Glucose tolerance testing should be done to rule out diabetic neuropathy. If lead poisoning is suspected, a blood level for lead should be done.
Physiologic
–Commonly seen in children less than 4 years old
- Infectious
–Viral and bacterial rhinosinusitis: Nasal congestion and obstruction lead to chronic mouth opening and contribute to drooling
–Adenotonsillar hypertrophy may cause drooling via nasal obstruction leading to persistent mouth opening to breathe
–Severe pharyngotonsillitis/tonsillitis causes an obstruction of swallowing
–Retropharyngeal or peritonsillar abscess similarly causes a physical obstruction of the swallowing mechanism
–Epiglottitis: Severe, life-threatening illness caused by Haemophilus influenzae type B, which causes rapid enlargement of the epiglottis; classic symptoms include drooling, a “perched” posture, respiratory distress
-
Inflammatory
–Allergic rhinitis
–Nasal polyposis
-
Congenital lesions
–Craniofacial syndromes
–Midline nasal masses, e.g., encephalocele
and glioma, may obstruct nasal breathing and require mouth breathing and therefore reduced swallowing
- Neurologic
–Cerebral palsy: Significant persistent drooling may occur secondary to impaired neuromotor control
–Cricopharyngeal achalasia and esophageal dysmotility are conditions of neuromotor dysgenesis in the smooth muscle
-
Trauma
–Caustic ingestion causes an increase in saliva production
–Laryngeal trauma may damage the structures necessary for swallowing
-
Dental
–Teething may cause an increase in drooling in an infant or a young child
–Dental caries may cause drooling because of pain and local irritation
-
Foreign body
Workup and Diagnosis
- History
–Severity (number of bibs or tissues saturated), onset,
duration
–Ability to eat and drink
–Recent URI, sinusitis
–Mouth breathing, snoring
–Severe neuromotor delay, recurrent or chronic
aspiration
–Prior conservative therapy
–Immunization history for HiB
-
Physical exam
–Fever, general appearance
–Head control (a child keeping head in continuous flexion may persist with drooling)
–Stridor, nasal obstruction, tonsillar size
–Tongue control, excoriations around the mouth
-
Studies
–Lateral skull X-ray when adenoid hypertrophy is suspected
–Flexible fiberoptic nasopharyngolaryngoscopy permits
visualization of nasal cavity, adenoids, larynx
–CT neck with contrast if abscess is suspected
–Modified barium swallow if swallowing difficulty or
chronic aspiration is suspected
–Further testing for chronic sialorrhea is seldom
necessary
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Facial Paralysis:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
Acquired
-
Bell palsy
–A diagnosis of exclusion; 40% of cases
-
Acute otitis media
–From erosion or dehiscence of facial canal
-
Chronic otitis media
–Nerve compression from granulation tissue
-
Herpes zoster oticus
–Often infects eighth nerve as well, with hearing loss and vertigo
-
Lyme disease
–Usually several weeks after inoculation
-
Tumors
–Temporal bone leukemia,
rhabdomyosarcoma of head and neck
-
Melkersson-Rosenthal syndrome
–Relapsing alternating facial paralysis
–Recurrent facial edema
–Fissured tongue
-
Temporal bone fracture
–Although most cases involve longitudinal fractures, transverse may also result in hearing loss and vertigo
-
Facial wounds
–Early repair if clean wound
–Tag nerve for delayed repair if dirty wound
-
Iatrogenic
–After otologic or parotid surgery
Congenital
-
Traumatic (associated with prolonged and difficult labor)
-
Inherited disorders
–Myotonic dystrophy: Progressive muscle weakness, facial paresis at birth
–Albers-Schönberg disease: Osteopetrosis increases bone density, compresses nerve
- Developmental abnormalities
–Möbius syndrome: Facial paralysis with 6th cranial nerve palsy
–Association with coloboma, heart defect, choanal atresia, genital hypoplasia, ear anomalies (CHARGE)
–Goldenhar syndrome, also known as oculoauriculovertebral (OAV) syndrome: First and second branchial arch abnormalities
–Asymmetric crying facies: Also called congenital unilateral lower lip palsy (CULLP)
Workup and Diagnosis
-
History
–Age of onset, rapid vs slow time-course, duration
–Prior episodes, trauma, neurologic disorders, ear disease
-
Physical exam
–Facial movement (e.g., while laughing, crying)
–Facial symmetry at rest
–Eye closure
–Tear production, tongue papillae atrophy
-
Audiologic testing
–Type of hearing loss predicts site of lesion (SNHL: internal auditory canal or CNS; CHL: middle ear)
-
Imaging studies
–CT best for detecting pathology within temporal bone
–MRI with gadolinium: Inflammation of nerve seen as
enhancement on scan; predicts poorer outcome
- Electrical testing
–Objective means of monitoring function
–Evoked electromyography (EEMG; electrically records muscle compound action potential; below 10% of normal side [i.e., 90% degeneration] predicts poor recovery; test must be done during first few days of paralysis)
–Electromyography (EMG): Voluntary action potentials predict excellent prognosis; fibrillation potentials predict poor prognosis; polyphasic voluntary action potentials indicate reinnervation; test most useful weeks after injury
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
FACIAL PARALYSIS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will frequently help determine the cause of facial paralysis. Peripheral facial palsy as occurs in Bell palsy involves the forehead muscles and there is difficulty in closing the eyelid, whereas central facial palsy involves the face and lips and there is often associated hemiplegia or monoplegia. When there is exclusively a peripheral facial palsy without hearing loss or other neurologic signs, Bell palsy should be strongly suspected, although diabetes and myasthenia gravis need to be excluded. A bilateral peripheral nerve palsy should make one consider Guillain–Barré syndrome and be on the look out for paralysis of the extremities as well. Bilateral facial palsy is also seen in myotonic dystrophy and myasthenia gravis. A “Bell palsy” with hearing loss and an aural discharge should prompt consideration of mastoiditis and petrositis. If there is hearing loss without a discharge, the possibility of an acoustic neuroma or cholesteatoma must be entertained. The association of a central facial palsy with hemiplegia brings up a host of possibilities including subdural hematoma, brain abscess, brain tumor, and cerebrovascular accident. The workup of these conditions is considered on page 545.
If the patient has clinical Bell palsy, one could start a therapy without a workup, but it is wise to get an x-ray of the skull and mastoids to rule out mastoiditis and petrositis and a glucose tolerance test to rule out diabetes. An acetylcholine receptor antibody titer or Tensilon test would only be ordered if the palsy were intermittent or there was other cranial nerve signs. If a middle ear infection or acoustic neuroma is suspected, the patient needs x-ray of the mastoids and petrous bones and a CT scan or MRI of the brain and auditory canal.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Drooling:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you observe the patient drooling, first determine the amount. Is it scant or copious? When did it begin? Ask the patient if his pillow is wet in the morning. Also, inspect for circumoral irritation.
Then explore associated signs and symptoms. Ask about sore throat and difficulty swallowing, chewing, speaking, or breathing. Have the patient describe pain or stiffness in the face and neck and muscle weakness in the face and extremities. Has he noticed mental status changes, such as drowsiness or agitation? Ask about changes in vision, hearing, and sense of taste. Also, ask about anorexia, weight loss, fatigue, nausea, vomiting, and altered bowel or bladder habits. Has the patient recently had a cold or other infection? Was he recently bitten by an animal or exposed to pesticides? Finally, obtain a complete drug history.
Next, perform a physical examination. Take the patient's vital signs. Inspect for signs of facial paralysis or abnormal expression. Examine the mouth and neck for swelling, the throat for edema and redness, and the tonsils for exudate. Note foul breath odor. Examine the tongue for bilateral furrowing (trident tongue). Look for pallor and skin lesions and for frontal baldness. Carefully assess any bite or puncture marks.
Assess cranial nerves II through VII, IX, and X. Then check pupillary size and response to light. Assess the patient's speech. Evaluate muscle strength, and palpate for tenderness or atrophy. Also, palpate for lymphadenopathy, especially in the cervical area. Observe the patient's ability to swallow, and assess his gag reflex. Test for poor balance, hyperreflexia, and a positive Babinski's reflex. Also, assess sensory function for paresthesia.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Bell's palsy:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis is based on clinical presentation: distorted facial appearance and the inability to raise the eyebrow, close the eyelid, smile, show the teeth, or puff out the cheek. Electromyography helps determine the severity of nerve damage. Blood tests may be done to rule out acute causes (sarcoidosis or Lyme disease). If no improvement is evident within several weeks of onset, magnetic resonance imaging will rule out other causes of dysfunction.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Drooling:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you observe the patient drooling, first determine the amount. Is it scant or copious? When did it begin? Ask the patient if his pillow is wet in the morning. Also, inspect for circumoral irritation.
Then explore associated signs and symptoms. Ask about sore throat and difficulty swallowing, chewing, speaking, or breathing. Have the patient describe any pain or stiffness in the face and neck and any muscle weakness in the face and extremities. Has he noticed any mental status changes, such as drowsiness or agitation? Ask about changes in vision, hearing, and sense of taste. Also ask about anorexia, weight loss, fatigue, nausea, vomiting, and altered elimination habits. Has the patient recently had a cold or other infection? Was he recently bitten by an animal or exposed to pesticides? Finally, obtain a complete drug history.
Next, perform a physical examination, starting with vital signs. Inspect the face for signs of paralysis or an abnormal expression. Examine the mouth and neck for swelling, the throat for edema and redness, and the tonsils for exudate. Note halitosis. Examine the tongue for bilateral furrowing (trident tongue). Look for pallor, skin lesions, and frontal baldness. Carefully assess any bite or puncture marks.
Assess cranial nerves II through VII, IX, and X. Then check pupillary size and response to light. Assess the patient’s speech. Evaluate muscle strength and palpate for tenderness or atrophy. Also palpate for lymphadenopathy, especially in the cervical area. Observe the patient’s ability to swallow. Test for poor balance, hyperreflexia, and a positive Babinski’s reflex. Also, assess sensory function for paresthesia.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Bell's palsy:
Diagnosis
(Handbook of Diseases)
Patients with Bell’s palsy typically have a distorted facial appearance and inability to raise the eyebrow, close the eyelid, smile, show the teeth, or puff out the cheek. After 10 days, electromyography helps predict the level of expected recovery by distinguishing temporary conduction defects from a pathologic interruption of nerve fibers.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Drooling:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If you observe the patient drooling, first determine the amount. Is it scant or copious? When did it begin? Ask the patient if his pillow is wet in the morning. Also, inspect for circumoral irritation.
Then explore associated signs and symptoms. Ask about sore throat and difficulty swallowing, chewing, speaking, or breathing. Have the patient describe pain or stiffness in the face and neck and muscle weakness in the face and extremities. Has he noticed mental status changes, such as drowsiness or agitation? Ask about changes in vision, hearing, and sense of taste. Also ask about anorexia, weight loss, fatigue, nausea, vomiting, and altered bowel or bladder habits. Has the patient recently had a cold or other infection? Was he recently bitten by an animal or exposed to pesticides? Finally, obtain a complete drug history.
Next, perform a physical examination. Take the patient's vital signs. Inspect for signs of facial paralysis or abnormal expression. Examine the mouth and neck for swelling, the throat for edema and redness, and the tonsils for exudate. Note foul breath odor. Examine the tongue for bilateral furrowing (trident tongue). Look for pallor and skin lesions and for frontal baldness. Carefully assess any bite or puncture marks.
Assess cranial nerves II through VII, IX, and X. Then check pupillary size and response to light. Assess the patient's speech. Evaluate muscle strength, and palpate for tenderness or atrophy. Also, palpate for lymphadenopathy, especially in the cervical area. Observe the patient's ability to swallow, and assess his gag reflex. Test for poor balance, hyperreflexia, and a positive Babinski's reflex. Also, assess sensory function for paresthesia.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
FACIAL PARALYSIS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will frequently help to determine the cause of
facial paralysis. Peripheral facial palsy as occurs in Bell palsy involves
the forehead muscles and there is difficulty in closing the eyelid, whereas
central facial palsy involves the face and lips and there is often
associated hemiplegia or monoplegia. When there is exclusively a peripheral
facial palsy without hearing loss or other neurologic signs, Bell palsy
should be strongly suspected, although diabetes and myasthenia gravis need
to be excluded. A bilateral peripheral nerve palsy should make one consider
Guillain–Barré syndrome; be on the lookout for paralysis of the
extremities as well. Bilateral facial palsy is also seen in myotonic
dystrophy and myasthenia gravis. A “Bell palsy” with hearing loss and an
aural discharge should prompt consideration of mastoiditis and petrositis.
If there is hearing loss without a discharge, the possibility of an acoustic
neuroma or cholesteatoma must be entertained. The association of a central
facial palsy with hemiplegia brings up a host of possibilities including
subdural hematoma, brain abscess, brain tumor, and cerebrovascular accident.
The workup of these conditions is considered on page 222.
If the patient has clinical Bell palsy, one could start a therapy without a
workup, but it is wise to get an x-ray of the skull and mastoids to rule out
mastoiditis and petrositis and a glucose tolerance test to rule out
diabetes. An acetylcholine receptor antibody titer or Tensilon test would
only be ordered if the palsy were intermittent or there were other cranial
nerve signs. If a middle ear infection or acoustic neuroma is suspected, the
patient needs x-ray of the mastoids and petrous bones and a CT scan or MRI
of the brain and auditory canal.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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