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X Clin Med III Exam 3 > Head and Facial Disorders > Flashcards

Head and Facial Disorders Flashcards

1
Q

Etiologies of facial palsy

A 
Infectious
Traumatic
Tumor
Cerebrovascular disease
Toxin exposure
Idiopathic (HSV goes here)
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2
Q

Risk for Bell’s palsy

A

Pregnancy (3x-increases during 3rd trimester and immediately postpartum)
Diabetes

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3
Q

Differential diagnosis of Bell’s palsy: Herpes zoster

A

Ramsay hunt syndrome (cephalic zoster with facial nerve involvement)
Vesicles near external meatus and ask about perherpetic neuralgia

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4
Q

Differential diagnosis of Bell’s palsy: otitis media

A

Possible complication

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5
Q

Differential diagnosis of Bell’s palsy: Lyme disease

A

Unilateral but typically BILATERAL lasting less than2 mos (maybe with lyme meningitis)
Eval in young pt and other associated sxs including erythema/swelling prior to palsy

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6
Q

Differential diagnosis of Bell’s palsy: Guillain Barre

A

Progressive, symmetric and bilateral

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7
Q

Differential diagnosis of Bell’s palsy: tumor

A

Gradual onset over 2+ weeks

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8
Q

Differential diagnosis of Bell’s palsy: stroke (central lesion)

A

Stroke spares forehead-upper motor neuron (rare for stroke to affect ipsilateral facial nerve nucleus or tracT)

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9
Q

What to think of with central facial palsy?

A

UMN lesion affects contralateral portion of lower face, forehead spared
Think STROKE, TUMOR, multiple sclerosis or trauma to motor cortex or corticobulbar tracts

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10
Q

What to think of with peripheral facial palsy?

A

LMN lesion affecting ipsilateral face (involves forehead)
Think of BELLS PALSY, Guillain Barre, otitis mesia, Lyme, Ramsay hunt syndrome
Still need to consider stroke and tumor tho

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11
Q

How to diagnose Bell’s palsy

A

Clinically
Diffuse facial nerve involvement
Acute onset in 1-2 days (progressive with max severity within 3 wks and improvement or recovery in 6 mos)

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12
Q

When to do diagnostic studies with Bell’s palsy?

A

Atypical sxs, no significant improvement in 4 mos or progression beyond 3 wks

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13
Q

What are the possible diagnostics that can be used with Bell’s palsy?

A

Electromyograph/nerve conduction study
CT/MRI
Labs (serological testing for lyme or HSV, fasting blood sugars in pts with risk factors of DM)

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14
Q

Mild cases of Bell’s palsy

A

May resolve spontaneously within 2 wks

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15
Q

Pharmacologic tx for Bell’s palsy

A

ALL pts!!!
Prednisone 60 mg daily x 5 days then taper by 10 mg daily x 5 days OR 60-80 mg daily x 7 days
Maybe valacyclovir 1g TID x 7 days

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16
Q

When do you see best results with pharmacologic tx of bells palsy?

A

If initiated within 3 days of sx onset

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17
Q

What to remember with eyes and Bells palsy

A

Increased risk of drying, corneal abrasion and corneal ulceration

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18
Q

Eye care for Bell’s palsy

A 
Artificial tears (liquid or gel preps) applied hourly
Eye ointmes (mineral oral and petrolatum) at night and maybe patch
Sunglasses
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19
Q

Prognosis of Bell’s palsy

A

Most improve in 3 wks (normal function returning in 3-6 mos)
If complete paralysis only 60% return to normal
If incomplete 94% return to normal

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20
Q

What might be seen with new axon growth in Bell’s palsy?

A

Disorganized/synkinesis- blinking causes twitch in corner of mouth or smiling causes eye to wink

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21
Q

What is trigeminal neuralgia?

A

Recurrent brief episodes of severe, unilateral pain along 5th CN (one or more branches of TN may be triggered)

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22
Q

How is pain with trigeminal neuralgia?

A

Like electrical shock-like sensation

23
Q

Incidence of trigeminal neuralgia

A

Increased with age, >50 YO

Women

24
Q

Different classifications of trigeminal neuralgia

A

Classic: idiopathic or vascular compression of trigeminal nerve root
Painful trigeminal neuropathy (secondary trigeminal neuropathy): other causes like herpes zoster, vestibular schwannoma, meningioma, cyst, LS

25
Q

Presentation of trigeminal neuralgia

A

Paroxyms of shooting pain lasting a few seconds and may occur repetitively (frequency varies, episodes of remission lasts for 6+ mos, recurrence if more frequent and disabling)
Usually unilateral presentation (most often V2 or V3)

26
Q

What kinds of sxs may be seen with trigeminal neuralgia if V1 is affected?

A

Autonomic

27
Q

Trigger zones with trigeminal neuralgia

A

Light touch may trigger an attack (pt guarding, chewing/ talking/shaving/brushing teeth)

28
Q

What is pretrigeminal neuralgia?

A

Continous, dull ache in jaw prior to classic sxs present (rule out dental causes)

29
Q

Diagnosis of trigeminal neuralgia due to international classification of HA disorders

A

At least 3 paroxysmal episodes of unilateral facial attacks (severe intensity, shock like shooting quality)
Affects trigeminal nerve distribution only
No neuro deficits

30
Q

What imaging if think secondary cause for trigeminal neuralgia?

A

MRI with and without contrast preferred

31
Q

Pharmacologic tx for trigeminal neuralgia

A

Carbamazepine (100 mg-200 mg BID): increase gradually with typical maintenance dose of 600 mg-800 mg total daily
Other anticonvulsant meds if can’t tolerate (oxycarbazepine, gabapentin, phenytoin)
Baclofen

32
Q

SE of carbamazepine

A

Drowsiness, dizziness, n/v, leukopenia and rarely aplastic anemia

33
Q

Labs needs for carbamazepine

A

Follow CBC routinely (HLA b1502 screening b/c increased risk for SJS)

34
Q

Other management for trigeminal neuralgia

A

Botox, glycerol, radiofrequency thermal lesioning

Surgery (refractory to meds): microvascular decompression, ablation like rhizotomy and gamma knife radiosurgery

35
Q

What is giant cell (temporal) arteritis?

A

Chronic vasculitis of medium and large vessels (diffuse inflammatory cells leading to wall thickening and decreased lumen)

36
Q

Arteries that might be affected in giant cell (temporal) arteritis

A

Ophthalmic artery occlusion: blindness

Basilar artery occlusion: brain stem infarct

37
Q

Incidence with giant cell arteritis

A

Increases with age (>50 YO and avg age 77)
Scandinavian descent
Some have polymyalgia rheumatica
Females

38
Q

Possible presenting sxs of giant cell (temporal) arteritis

A

New HA (extracranial vessel involvement-unilateral severe HA with throbbing sensation and aggravated by pressure or cold exposure)
Visual disturbances: diplopia or transient blindness (amaurosis fugax)
Sxs with polymyalgia rheumatica
Jaw claudication is pathognomic
Unexplained fever or other constitutional sxs (fever, fatigue, weight loss)

39
Q

PE for giant cell (temporal) arteritis

A

Vision eval
Tender, palpable temporal artery (pulse is decreased or absent, auscultate for bruits)
Muscle tenderness in neck and shoulders
Check for carotid bruits

40
Q

Labs for giant cell (temporal) arteritis

A

Anemia maybe
ESR is most USEFUL screening tool (>50 mm/hr is 95%)
CRP elevation

41
Q

Temporal artery biopsy with giant cell (temporal) arteritis

A

Minimum of 1-2 cm section of artery (skip lesions)

Presence of multi nucleated cells is diagnostic

42
Q

American college of rheumatology diagnostic criteria for giant cell (temporal) arteritis

A 
3/5 needed:
Age on onset>50 YO
New, localized HA
Temporal artery tenderness, decreased temporal pulse
ESR>50 mm/hr
Positive temporal artery biopsy
43
Q

Management goal of giant cell (temporal) arteritis

A

Prevent blindness or stroke

44
Q

Management of giant cell (temporal) arteritis

A

Promptly initiate glucocorticoid tx (prednisone 40-60 mg daily and taper in 2-4 wks but continue with 10-20 mg faily for 9-12 mos)
If recurs then may need lifelong steroids
Follow ESR/CRP

45
Q

What is temporomandibular joint dysfunction?

A

Pain associated with TMJ misalignment
Muscular hypertrophy with malocclusion
Arthritis: degeneration of articular surface

46
Q

High risk of TMJ

A

Rheumatoid arthritis

47
Q

What might be associated with TMJ?

A

20-40 YO
Bruxism, gum chewing, pencil biting, pipe smoking, musical instruments involving repetitive jaw motions, trauma, mood and psych disorders

48
Q

Presentation of TMJ

A

Periauricular pain and tenderness of TMJ and muscles of mastication (HA or ear discomfort, radiate to ear/ temporal/periorbital regions)
Crepitus with movement (clicking or popping)

49
Q

PE for TMJ

A

Subluxation and dislocation of jaw (catching vs locking)
Decreased ROM (demonstrate asymmetric opening and closing-malocclusion)
Abnormal dental wear

50
Q

How to diagnose TMJ

A

Clinical

51
Q

Other diagnostics for TMJ

A

Plain films: evaluate erosions, osteophytes, arthritis

CT?MRI: extreme pain, abnormal radiographs, changes in cranial nerves, previous surgery to TMJ

52
Q

Management of TMJ

A

Dental referral PRN
Heat
Soft diet, avoiding repetitive chewing (gum)
Jaw exercises
Oral appliances (occlusal splints) may be beneficial

53
Q

Pharm therapy for TMJ

A

Chronic pain- tylenol, NSAIDs, muscle relaxants

X Clin Med III Exam 3 (7 decks)

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