A case of CVA in the RVH ER… Chenjie Xia (PGY-3) AHD Interactive Case Wednesday, Feb. 23rd, 2011
On call at the RVH… RVH ER page at 9:30PM Code purple, please see stroke patient for admission…
Patient Background ID: 74M, right handed RFC: stroke Social history: Chinese origin, retired real estate agent, lives with wife
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)
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
History Woke up this AM and notes new right facial weakness, i.e. right mouth droop
What more do you want to know on history?
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
More history Right sided headache x few months Increased pain in right parotid tumour x Nov. 2010. Consulted multiple MDs (GP, ENT, neurologist) Ultrasound shows stable right parotid mass? Suboptimal pain control despite Celebrex, Dilaudid and Lyrica
What is your differential at this point?
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
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
What more do you want to know on exam? Be specific…
More exam findings No aphasia Large, palpable, firm, tender right parotid mass Pupils 21mm (bilat), VFs normal, EOMs (saccadic SP, otherwise normal) Normal sensation (LT/PP) Right facial droop (frontalis, orbicularis oculi, and orbicularis oris involved)
How do you differentiate between UMN and LMN facial palsy?
Can you name the main motor branches of the facial nerve?
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)
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
What is your top differential diagnosis at this point?
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
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
Findings CT head: old left putamen lacune, nil acute
Question Does the decreased taste favor Bell’s palsy or facial nerve injury secondary to parotid lesion?
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
Question Can you name the 4 functional categories of the facial nerve and briefly describe what they do?
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
Question With the help of the diagram, can you point out the nerves and ganglia involved in each of the functional categories?
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
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
Parasympathetic (1) Superior salivatory nucleus GT petrosal nerve leaves genu Reach the sphenopalatine ganglion post-ganglionic fibers lacrimal glands
Parasympathetic (1) Superior salivatory nucleus GT petrosal nerve leaves genu Reach the sphenopalatine ganglion post-ganglionic fibers lacrimal glands
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
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
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)
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)
General Somatic Sensory Region near external auditory meatus Synpase in spinal trigeminal nucleus
General Somatic Sensory Region near external auditory meatus Synpase in spinal trigeminal nucleus
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