# Facial Paralysis HUH?



## MMiz (Jun 10, 2007)

Okay, another case I heard of and said "Yeah... that's it."  I honestly have no clue where to go with this one.

EMS dispatched to home of 30 y/o male patient.  ATF pt sitting upright in chair.  Pt states that over the past few hours they have lost sensation in right side of face.
S:  Facial droop on R side.  Unable to blink eye on R side. Facial pain.  Full trauma/medical assessment finds no additional abnormalities.
A: Denies
M: No medical history.  Patient is in peak physical health and exercises daily.  Pt has no psych history.
P: Facial pain that the pt describes as dull and rates a 3 on 1-10 scale.
L: One hour ago
E: Patient was sitting down relaxing with significant other and noticed a slow deterioration of their ability to control R side of face.  Called EMS when pt was unable to blink.

All vitals are unremarkable and normal for a healthy person.

Any ideas?

Highlight following text with your cursor to find out DX [Neurologist's DX was Bell's Palsy???  What's the pre-hospital treatment on that?]


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## akflightmedic (Jun 10, 2007)

As I was reading your post I was shaking my head in agreement. I knew exactly what you were describing only because I remember many moons ago when I too had a similar case only in a younger female. It threw me for a loop as I had never heard of Bells Palsy.


The condition itself is pretty benign. Pre hospital measures consist of supportive care and making sure you have ruled out any other potential causes. The patients are usually very distressed as they are thinking the worst and suspecting a CVA. 

It happens when the 7th cranial nerve recieves an insult of some sort. Onset can be between waking up with it to noticing tingling lips that worsens that day or over the next few days to include the side of the face. Recovery depends on severity of insult and can be days to months before full recovery.

Just because your patient is young, healthy and has great vitals, do not skip  performing a detailed neuro exam to rule out other injuries or CVA. Do not let this condition tunnel vision you into missing a CVA or TIA in the future. Bells Palsy is confined strictly to one side of the face. If any other body part is weak, numb, or paralyzed, it is not Bells Palsy, there is a different underlying cause.


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## MMiz (Jun 10, 2007)

Thanks for the info.  Is there any pre-hospital treatment?  I'm not sure there is any treatment at all.  O2?  How would one know the difference between this and a stroke?  Do you treat all patients that present with this as a stroke?  I'd hate to delay treatment only because I've seen this before and thought it wasn't serious.


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## Airwaygoddess (Jun 10, 2007)

Just support treatment, nero checks, BP checks in both arms.  Sometimes Bell's palsy can be triggered by a viral or bacterial infection.  It makes for interesting reading.


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## VentMedic (Jun 11, 2007)

Bell's Palsy doesn't discriminate and can happen to almost anyone.


http://www.bellspalsy.ws/


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## Ridryder911 (Jun 11, 2007)

I use a differential taught to me by an ER Doc, to test for Cranial Nerve Seven (Facial nerve, which may be damaged per viral, bacterial or even trauma) is to check for the eye brow to raise up and down, and eyelid to close, not to be confused with ptosis (drooping of the eyelid associated with CVA). Usually or more common, in CVA ptosis or facial drooping is more associated with the eye lid, not individual as seen in Bell's Palsy. 

Bells Palsy very common and the symptoms is usually associated acutely, and no other symptoms are associated. 

Many times the treatment is only comfortive ( eye drops, patch) 
R/r


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## RedZone (Jun 26, 2007)

The first thing that came to my mind was Bell's Palsy, as others have mentioned.

But my mom also had a similar event a long time ago.  She had slurred speech and temporary one sided facial paralysis.  I didn't know much about medicine at the time, but I rushed her to the hospital assuming she had a stroke.  They did do a cat-scan and ruled out CVA.  She gradually got better in the ER, and the doctor told her it was a "very bad migraine".    She does have a history of migraines.

I don't know if I buy that.  Maybe ridryder or someone else can offer their opinion?


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## RichmondMedik (Jun 26, 2007)

Trigeminal Neuralgia and TMJ can also affect only one side of the face and cause untolerable pain -- just throwing out other conditions


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## mtmedic (Aug 25, 2007)

Several years back I worked as a CNA and worked with an RN that had Bells Palsy and never regained her ability to smile on the left side.  She got all other facial control back and that was 20 years ago.  Ironically I was dispatched to a 69 y/o female on Thursday with a CC of numbness on the L side of her face.  UA she described the sx as having been to the dentists and her cheek and tongue were numb.  Further evaluation revealed systemic sx as well.  The most obvious being weakness in the left leg and foot when CMS was evaluated and the fact that her speech began becoming increasingly slurred.  Onset was only 15-20 minutes prior to EMS activation and I made the decision to expedite transport as I believed this to be suspect of a mounting CVA.  She reported no PMH, surgeries, or major illnesses and told me she was "healthy as a horse".  CT later revealed several small areas of concern so an MRI was ordered.  Her husband later told me she has had dizzy spells over the last few months but refused to see a Dr.  I think that will all change now...  So long story short as we were heading to the call I was thinking how interesting it might be to have a Bells Palsy and was filling in my partner on some of the symtomology.   Oh well maybe another day...


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## medicdan (Aug 25, 2007)

This is all very interesting; I am going to do some more research on this. 

Question: Can/Does Bells Palsy happen to both sides of the face? This may be getting too complicated, but how is it determined what side is to be effected? 

R/R commented that it occurs fairly commonly-- what does that mean? What percentage of the population is effected?

I am going to go off and do my research... when I answer my own questions I will come back.

Thanks!!
DES


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## bonedog (Aug 25, 2007)

My little buddy's best friend had VZV infect his brain via the trochlear route, bad out come...


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## sandboxmedic (Aug 26, 2007)

Ridryder911 said:


> I use a differential taught to me by an ER Doc, to test for Cranial Nerve Seven (Facial nerve, which may be damaged per viral, bacterial or even trauma) is to check for the eye brow to raise up and down, and eyelid to close, not to be confused with ptosis (drooping of the eyelid associated with CVA). Usually or more common, in CVA ptosis or facial drooping is more associated with the eye lid, not individual as seen in Bell's Palsy.
> 
> Bells Palsy very common and the symptoms is usually associated acutely, and no other symptoms are associated.
> 
> ...


i remember reading somewhere in my travels, that besides viral,bacterial, or trauma there was another possibility for Bells Palsy. Apparently, i remember this because it sounded so "off the wall". Something to the affect of cool/cold air constantly blowing over 1 side of the face for prolonged periods of time causeing this to spontaneously happen as well. Cases referenced were : 1 patient who slept with a box fan blowing air on his face, while one side stayed warm, the other side developed this droop. 2nd case: was a truck driver who always had his window cracked open, contstantly blowing on his left side, developed the droop on that side as well ( it was winter ). You ever heard of this?


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## mtmedic (Aug 26, 2007)

sandboxmedic said:


> i remember reading somewhere in my travels, that besides viral,bacterial, or trauma there was another possibility for Bells Palsy. Apparently, i remember this because it sounded so "off the wall". Something to the affect of cool/cold air constantly blowing over 1 side of the face for prolonged periods of time causeing this to spontaneously happen as well. Cases referenced were : 1 patient who slept with a box fan blowing air on his face, while one side stayed warm, the other side developed this droop. 2nd case: was a truck driver who always had his window cracked open, contstantly blowing on his left side, developed the droop on that side as well ( it was winter ). You ever heard of this?





Now that you mention it...  I do remember reading this somewhere.  I know it was in school a few years back or during clinicals but can't remember which one it was...


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## BruceD (Oct 6, 2007)

Hey guys -

emedicine has what appears to be an excellent and recently updated article on Bell's Palsy (especially check out the physical and differential section)

http://www.emedicine.com/emerg/topic56.htm

But - be very careful, it is a diagnosis of exclusion.  Make sure you rule out all the other, much more emergent, causes of facial paralysis.  

For the most part though, Bell's Palsy will resolve by itself in a few weeks.  
(some small percentage of patients appear to have chronic problems with taste or tears).

tc
-B

edit--
btw, I *think* the idea that wind blowing on someones face could initiate Bell's palsy originates from lore.  Although some references point to this as the cause, the ones I found were also trying to sell homeopathic remedies for the palsy just below this stated 'cause'.


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## DisasterMedTech (Oct 8, 2007)

Its my understanding that Bell's Palsy by definition only affects on side of the face. I have never seen it any other way.


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## jrm818 (Oct 19, 2007)

Interesting...stumbled over this today for a class.  Apparenlty inflammation is a big part of the picture with this affliction.

the full article is in the NEJM for those of you who have access / are interested.

http://www.medpagetoday.com/Neurology/GeneralNeurology/tb/7004


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## DisasterMedTech (Oct 19, 2007)

Limited experience aside:

So far I have seen Bells Palsey x 2 patients: Ive only ever seen it on one side of the face and believe that by definition if its on two, start looking for other etiology cause it aint Bell's.

CVA/TIA x4 pts so far. For us Basics, remember things like your Cincinnati stroke scale. Put your patient through their paces while giving supportive assistance like 12-15 via NRB (this is what I was taught). Have them life both arms with eyes closed and count to ten, if one drifts off to the side, start thinking CVA/TIA. Have your. patient stick out their tongue. It should be midline. Wandering off to one side is a bug stroke indicator. Have your patient say the phrase "You cant teach an old dog new tricks." The combination of sounds here will produce slurring and also show you memory looping/lapses which would not really be associated with bells. Watch for that unilateral facial droop, inability to blink or close the eye. If you patch it or wet to dry it, they may be more comfortable. Pupil reaction may be slow on both sides and really unequal or misshapen on the side OPPOSITE the side of the brain effected by stroke. Give them three simple words: I will use fire-truck, President, Christmas. Tell them to remember them and then go on with something else. About 2 minutes later ask them to repeat your words in order. If they cant, add this to your other gathered info about CVA. Its also important to remember that while a full blown CVA sx may worse over time you are with your pt, the TIA (transient aschemic attack) may actually start to get better in your presence. The patient I had with TIA started to "recover" in about 10 minutes almost like post-ictaly. By the time we were at the hospital door, if I hadnt seen them 20 minutes ago I would have been hard pressed to tell anything was wrong. TIA s and sx will usually resolve fully between 12 and 36 hours post event, where such is often not the case with a full blow CV accident.

Just my two cents. YMMV.

PS- Consider no lights and sirens with any cerebral accident or event. Your choice, it seems to me, should be based on your patients ABCs and your medics interventions and interpretations of EKG and other testing he/she has done. Always remember to ask your medic how they wish to travel. I always do and they seem to appreciate it.  Traveling hot with L/S can trigger further undesirable post event Sx. We have a protocol to never use L/S with post-ictal seizure pts if it can be avoided. Also remember that strokes, because of the poor health or the American population, are becoming more commong. Just because your pt is 28, dont rule it out. Watch out for tunnel vision, it will get you every time.

clear on emtlife 1.


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## Ridryder911 (Oct 19, 2007)

Actually, acute CVA is one of the few 3 or 4 things, I run with L/S back to the ER with.

The time window of being able to administer thrombo's for CVA is only about 3 hrs from time of onset. Many times, the patient will ignore the symptoms or not be found until later.  The Mercy technique that actually goes into the cerebral artery time line is longer, but very controversial even among Neurologist and Strokologist. 

I highly recommend Paramedics to take the Advanced Stroke Life Support Course (ASLS). I attended and then became an instructor for them. The nice thing is it was a traditionally prehospital program, then developed into the  ER's was just as poorly educated in CVA's as well. So both ICU/ER/ EMS can attend with special break out sessions for each speciality. It represents EMS nice, with education in advanced neuro assessments and evaluation and determination of location of strokes. 

R/r 911


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## jrm818 (Oct 19, 2007)

Hey rid, just curious, what are the other 2 or 3?

I would guess that one is trauma which requires surgery ASAP...but I'm not sure what else.  I'm assuming the other one isn't an arrest, but maybe other cardiac issues?  Sepsis perhaps?


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## reaper (Oct 19, 2007)

L&S for a few things.

1. CVA
2. STEMI
3. Trauma Alert
4. Code

Most everything else is manageable en route.

Remember with a CVA, Time is Brain cells!!


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## Ridryder911 (Oct 19, 2007)

reaper said:


> L&S for a few things.
> 
> 1. CVA
> 2. STEMI
> ...



that pretty well says it.. Personally, I would go in without L/S on codes, but  firefighters tend to get irritated on stopping at red lights, stop signs.. when doing CPR... 

Seriously, if it is a * true emergency*  that is time sensitive, and of course dependent upon the situation... i.e dissecting AAA etc... 

R/r 911


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