1. A case of CVA in the RVH ER…
Chenjie Xia (PGY-3)
AHD Interactive Case
Wednesday, Feb. 23rd, 2011

2. On call at the RVH… RVH ER page at 9:30PM
Code purple, please see stroke patient for admission…

3. Patient Background ID: 74M, right handed RFC: stroke
Social history: Chinese origin, retired real estate agent, lives with wife

4. Patient Background PMHx: HCC with cirrhosis Diabetes HTN
Dx since 2006, s/p radiofrequency ablation, RTX
Episodic encephalopathy
Esophageal varices
Diabetes
HTN
Left putamen lacunar infarct
Right sided parkinsonian Sx, now resolved
ASA discontinued due to bleed from esophageal varices
Gout
Right parotid tumour (biopsy 2008  pleomorphic adenoma)

5. Patient Background Meds All: Habits
Allopurinol, MVI, Ca/Vit D, Mg, Remeron, HCTZ, Nadol, lactulose, Flagyl, lantus
Recently added: Celebrex, Dilaudid, Lyrica
All:
NKDA
Habits
Non-smoker, non-drinker

6. History
Woke up this AM and notes new right facial weakness, i.e. right mouth droop

7. What more do you want to know on history?

8. More history
Isolated right facial droop, i.e. no arm or leg weakness, no sensory change, no speech difficulties
Feels lips “thickened” and right eyelid “stuck to eyeball”
Right ear deaf for many years, no change
No change in taste noted
No vertigo, no n/v

9. More history Right sided headache x few months
Increased pain in right parotid tumour x Nov
Consulted multiple MDs (GP, ENT, neurologist)
Ultrasound shows stable right parotid mass?
Suboptimal pain control despite Celebrex, Dilaudid and Lyrica

10. What is your differential at this point?

11. Differential Diagnosis
Idiopathic facial nerve palsy (Bell’s palsy)
Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)
Stroke
Right brainstem (pons)
Left hemisphere

12. On exam
Looks well, non toxic, head drooped (because “the light is bothering my right eye”)
BP 155/70, HR 62 (reg), RR 20, 100% (RA), 36.1oC
No carotid bruit, normal S1, S2

13. What more do you want to know on exam?
Be specific…

14. More exam findings No aphasia
Large, palpable, firm, tender right parotid mass
Pupils 21mm (bilat), VFs normal, EOMs (saccadic SP, otherwise normal)
Normal sensation (LT/PP)
Right facial droop (frontalis, orbicularis oculi, and orbicularis oris involved)

15. How do you differentiate between UMN and LMN facial palsy?

17. Can you name the main motor branches of the facial nerve?

19. Muscles innervated by the Facial Nerve
The: Temporal branch
Zebra: Zygomatic branch
Bit: Buccal branch
My: Mandibular branch
Carrot: Cervical branch
(Stapedius and post. auricular branches)

20. More Exam Findings Taste: decreased on right hemi-tongue
Hearing: No lateralization on Weber, decreased air conduction on Rinne on the right
Palate, SCM, trap, tongue mvts normal
Rest of exam (tone, strength, reflexes, sensation, coordination, gait) unremarkable

21. What is your top differential diagnosis at this point?

22. Differential Diagnosis
Idiopathic facial nerve palsy (Bell’s palsy)
Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)
Stroke
Right brainstem (pons)
Left hemisphere

23. Differential Diagnosis
Idiopathic facial nerve palsy (Bell’s palsy)
Facial nerve palsy from other causes (e.g. infectious, autoimmune, granulomatous, neoplastic, etc)
Stroke
Right brainstem (pons)
Left hemisphere

24. Findings
CT head: old left putamen lacune, nil acute

25. Question
Does the decreased taste favor Bell’s palsy or facial nerve injury secondary to parotid lesion?

26. Facial nerve enters parotid gland after it exits the stylomastoid foramen; fibers carrying taste and subserving lacrimation should NOT be affected.
However, in malignant lesion, extension of lesion may very well invade nearby nerve branches

27. Question
Can you name the 4 functional categories of the facial nerve and briefly describe what they do?

28. Answer 1) Branchial motor 2) Parasympathetic
Muscles of facial expression
Stapedius muscle
2) Parasympathetic
Lacrimal glands
All salivary glands (e.g. submaxillary, submandibular) except parotid
3) Visceral sensory (special)
Taste from anterior 2/3 of tongue
4) General somatic sensory
Sensation from small region near external auditory meatus

29. Question
With the help of the diagram, can you point out the nerves and ganglia involved in each of the functional categories?

30. Branchial motor Facial nucleus Facial nerve exits at CPA
Traverses internal auditory meatus
Turns at genu
Exits at stylomastoid foramen
Passes through parotid gland
Divides into branchial motor branches

31. Branchial motor Facial nucleus Facial nerve exits at CPA
Traverses internal auditory meatus
Turns at genu
Exits at stylomastoid foramen
Passes through parotid gland
Divides into branchial motor branches

32. Parasympathetic (1) Superior salivatory nucleus
GT petrosal nerve leaves genu
Reach the sphenopalatine ganglion
post-ganglionic fibers  lacrimal glands

33. Parasympathetic (1) Superior salivatory nucleus
GT petrosal nerve leaves genu
Reach the sphenopalatine ganglion
post-ganglionic fibers  lacrimal glands

34. Parasympathetic (2) Superior salivatory nucleus
Chorda tympani branches off before the stylomastoid foramen
Goes through petrotympanic fissure
Joins lingual nerve
Submandibular ganglion
postganglionic fibers  submandibular and sublingual glands

35. Parasympathetic (2) Superior salivatory nucleus
Chorda tympani branches off before the stylomastoid foramen
Goes through petrotympanic fissure
Joins lingual nerve
Submandibular ganglion
postganglionic fibers  submandibular and sublingual glands

36. Visceral sensory (Special)
Sensory fibers carrying taste from anterior 2/3 of tongue
Cell bodies in geniculate ganglion
Synapse onto secondary neurons in the rostral nucleus solitarius
Travel via CTT  VPM nucleus of thalamus  cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula)

37. Visceral sensory (Special)
Sensory fibers carrying taste from anterior 2/3 of tongue
Cell bodies in geniculate ganglion
Synapse onto secondary neurons in the rostral nucleus solitarius
Travel via CTT  VPM nucleus of thalamus  cortical taste area (inferior margin of postcentral gyrus, extends into parietal operculum and insula)

39. General Somatic Sensory
Region near external auditory meatus
Synpase in spinal trigeminal nucleus

40. General Somatic Sensory
Region near external auditory meatus
Synpase in spinal trigeminal nucleus

41. F/U Imaging CT neck (compared to Nov 2010)
Significant increase in mass size compared to Nov.
Peripheral enhancement, central area of necrosis
Extension into deep lobe
Possibility of malignant transformation