EM Vivas · Bell palsy and cranial nerve palsies
Bell palsy — forehead test, steroids and dangerous mimics viva
Clinical viva on LMN/UMN discrimination, Sullivan steroids, eye care, Ramsay Hunt, and PCOM aneurysm CN III.
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Interpretation
Reveal interpretationShowHide
LMN vs UMN. Ask the patient to raise both eyebrows and close both eyes. Forehead involvement with incomplete eye closure = LMN (Bell pathway). Forehead sparing with lower-face weakness = UMN — stroke pathway until proven otherwise.[2]
Typical Bell. Normal otoscopy, isolated CN VII, maximal within 72 h → prednis(ol)one within 72 h plus mandatory corneal protection (lubricants, night taping).[1]
Ramsay Hunt. Vesicles + otalgia ± hearing loss → steroid plus antiviral.[2][4]
CN III pupil-involving. Ptosis, down-and-out eye, dilated pupil → posterior communicating artery aneurysm until proven otherwise — urgent CTA, SAH pathway if indicated.[3]
Bilateral facial palsy. Not Bell — needs systemic work-up and admission as needed.[2]
References4ShowHide
- [1]Sullivan FM, Swan IR, Donnan PT, et al. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med, 2007.PMID 17942873
- [2]Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg, 2013.PMID 24189771
- [3]Lee AG, Hayman LA, Brazis PW. The evaluation of isolated third nerve palsy revisited: an update on the evolving role of magnetic resonance, computed tomography, and catheter angiography. Surv Ophthalmol, 2002.PMID 11918895
- [4]Uscategui T, Dorée C, Chamberlain IJ, Burton MJ Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev, 2008.PMID 18843734