Straightforward case of Bell's Palsy?

[DrQuinn]

So just curious... how do you all work up your cases of isolated 7th nerve palsy? (i.e. Bell's Palsy)? I've had half my attendings say it is a clinical diagnosis, and as long as you dont' suspect tumor or stroke, and the patient has decent follow up, you don't need imaging.

I've had other attendings say you need CT at minimum, and yet a few even say "all Bell's Palsy patients should get MRI."

Since I'm going to be on my own in 8 months, I am still getting a feel for what I would do.

I've CT'd people's beans for a lot less reason... and the Lyme titer I'm not waiting for in the ED....

Q

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[spyderdoc]

So just curious... how do you all work up your cases of isolated 7th nerve palsy? (i.e. Bell's Palsy)? I've had half my attendings say it is a clinical diagnosis, and as long as you dont' suspect tumor or stroke, and the patient has decent follow up, you don't need imaging.

I've had other attendings say you need CT at minimum, and yet a few even say "all Bell's Palsy patients should get MRI."

Since I'm going to be on my own in 8 months, I am still getting a feel for what I would do.

I've CT'd people's beans for a lot less reason... and the Lyme titer I'm not waiting for in the ED....

Q

Here on the West Coast, I usually don't work up the straight forawrd cases w/ complete hemi-face paralysis. I know, I know....about 2-5% of central lesions result in comlete facial nerve paralysis...
A CT is gonna have a hard time showing any pathology back there. Although I remember seeing in one of those journals recently, there was a case reported with a CT that showed a tiny stem bleed that presented as a Bell's. But REALLY, how ofter are ya gonna see that? Good luck trying to get an MRI.
Now it was different during my residency days in CT. We LP'ed most of them for CSF Lyme.
Now, if they don't have complete paralysis of the affected side of the face, if other CN's are involved, or other signs of CVA are present, then more w/u is definetly needed...

 

[DrQuinn]

Here on the West Coast, I usually don't work up the straight forawrd cases w/ complete hemi-face paralysis. I know, I know....about 2-5% of central lesions result in comlete facial nerve paralysis...
A CT is gonna have a hard time showing any pathology back there. Although I remember seeing in one of those journals recently, there was a case reported with a CT that showed a tiny stem bleed that presented as a Bell's. But REALLY, how ofter are ya gonna see that? Good luck trying to get an MRI.
Now it was different during my residency days in CT. We LP'ed most of them for CSF Lyme.
Now, if they don't have complete paralysis of the affected side of the face, if other CN's are involved, or other signs of CVA are present, then more w/u is definetly needed...

I agree, and that's what I think I'm gonna do when I'm done in 8 months... unless the patient has absolutely no follow up...

There was that case in Annals last year, some 36 year old dood presented with bell's palsy, but the authors even said they wouldn't have ordered a CT unless the patient hadn't said "I had an abnormal brain scan yesterday."

Q

 

[southerndoc]

Now it was different during my residency days in CT. We LP'ed most of them for CSF Lyme.

Spyderdoc, nothing has changed. I LP'd a patient three days ago who was subsequently diagnosed with Lyme disease as causing his left-sided facial parasthesias.

Gotta love Connecticut... Lyme capitol of the world.

 

[margaritaboy]

Clinical diagnosis.