Case 1

39 yo F with PMH of DM, asthma presents c/o R-sided facial weakness and R-eye blurry vision. She reports waking up with these symptoms this morning. ROS negative.

Notable exam findings:

POC glucose 111

R-facial droop with inability to fully raise R-eyebrow or wrinkle R-forehead

Visual acuity 20/20 BL

mental status, remaining CNs, motor, sensory, DTR, and cerebellar exams WNL

ear and nose exams WNL

Diagnosis?

Bell’s Palsy!

A few more basics

Etiology – idiopathic

Diagnosis of exclusion - based on the H&P

Ramsay-Hunt syndrome

Lyme disease

Sarcoidosis, Amyloidosis, Sjogren’s

Trauma

CNS pathology including stroke

Many possible associated symptoms…

Prognosis and Treatment

Bottom line = 10% of pt’s have some degree of

permanent facial paralysis!

Placebo:

6 months – 65% have complete recovery

9 months – 85% have complete recovery

10 days Prednisone:

6 months – 85% have complete recovery

9 months – 95% have complete recovery

NNT 11

The Controversy

Should we give antivirals too?

Maybe…

Cochrane reviews + 2007 NEJM Sullivan trial say no

2007 Hato trial says yes, if severe (not blinded!)…

10 days steroid + 5 days Valacyclovir in severe Bell’s:

Combo - 95% complete recovery

Steroid + placebo – 86% complete recovery

P < 0.05

Eye patch!

Case 2

59 yo M with PMH of HTN, arthritis presents c/o “dizziness”. This “room-spinning” sensation started last night and has recurred 3 times since lasting 15 seconds-1 minute each time. Triggered by head movement. ROS positive for associated diaphoresis and nausea.

Abbreviated exam findings:

VS WNL

POG glucose 111

Rightward horizontal nystagmus on EOMs

mental status, remaining CNs, motor, sensory, DTR, and cerebellar exams WNL

EKG NSR

Likely diagnosis?

Peripheral Vertigo!

Critical Approach

Step 1: Is this true vertigo?

Step 2: If so, is it Peripheral or Central

vertigo?

Step 1: Is this true vertigo?

What kind of “dizziness” does your pt have?

Vertigo

A feeling of movement or spinning when no actual

movement is occurring

Pre-syncope

Generalized weakness

Disequilibrium

Step 2: Peripheral or Central?

Peripheral – inner ear labyrinth or CN VIII

Labyrinthitis

Vestibular neuronitis

Ramsay-Hunt syndrome

BPPV

Meniere’s disease

Ototoxicity

Motion sickness

Trauma

Central – brainstem vestibular nuclei or cerebellum

Verterbrobasilar TIA/stroke (ischemic or hemorrhagic)

Vertebrobasilar dissection

Vertebrobasilar migraine

MS

Mass

Step 2: Peripheral or Central?

History clues:

Other than possible hearing loss and/or tinnitus, Peripheral Vertigo should NOT cause any other neuro abnormalities!

Important questions:

PMH?

Any associated symptoms?

tinnitus, hearing loss

HA, syncope, double vision, focal weakness, numbness, ataxia

Vertigo in the past?

Any recent illnesses or new medications?

Any preceding symptoms?

Any exacerbating factors?

Beware of Vertebrobasilar TIAs!

Step 2: Peripheral or Central?

Physical clues:

HINTS exam - on select patients

Head Impulse test

direction changing Nystagmus test

Test of Skew

Standard Neuro exam

Ambulate!

Neck auscultation

Inner ear exam

Only use on appropriate patients!

- Not BPPV

- Low risk…

HINTS Exam

Nystagmus

HINTS exam c/w Peripheral Vertigo:

https://www.youtube.com/watch?v=Wh2ojfgbC3I (HI)

http://journals.lww.com/continuum/pages/videogallery.aspx?videoId=3&autoPlay=true (N)

http://journals.lww.com/continuum/pages/videogallery.aspx?videoId=2&autoPlay=true (TS)

HINTS exam c/f Central Vertigo:

Normal HI

https://www.youtube.com/watch?v=B0ihEfYXPs0 (N)

https://www.youtube.com/watch?v=x2mOTHZscY8 (TS)

Why do we care?

A major fork in the road:

clinically diagnosed Peripheral Vertigo and low risk:

POC glucose, EKG

Improves with Rx > ambulate > discharge

clinically suspected Central Vertigo:

ED labs/imaging + neuro and admission for MRI/MRA

*includes elderly pt’s with risk factors whose symptoms are

not associated with position changes

*definitely includes pt’s who cannot walk

Case 3

62 yo M from Mexico with PMH of “nerve disorder” on “medication” bib family for severe weakness. Family states that yesterday he developed BL drooping eyelids, quiet voice, and difficulty swallowing similar to past episodes. This AM, his symptoms seemed relatively better but now they have returned and he is having trouble breathing.

Notable exam findings:

RR 30 with shallow breathing

BL ptosis

Quiet voice

2/4 strength to BL UE/LE

Underlying disorder?

Two “can’t miss” diagnoses?

Myasthenia Gravis!

Myasthenic

Respiratory Crisis

OR

Cholinergic Crisis

(that is the question!)

Myasthenia Gravis

autoantibodies block and destroy Ach-R at the neuromuscular junction

weakness

*eyes (ptosis, decreased EOMs +/- binocular diplopia, end-gaze nystagmus)

bulbar muscles (dysarthria, dysphagia, weakness with chewing)

proximal limbs and neck extensors

“the great imitator”

Clues:

“I have Myasthenia Gravis”

*weakness worsens with prolonged muscle use (“worse at night”) and improves with rest

usually no abnormalities on sensory, DTR, cerebellar testing

some key ddx – CNS mass lesion, thyroid disorder, Lambert-Eaton syndrome, Botulism, etc

Myasthenic Respiratory Crisis

A state of severe weakness including the respiratory

muscles, leading to respiratory failure

Just think of it as a Myasthenia Gravis “exacerbation”

Approximately 20% lifetime incidence!

Leading cause of death!

Causes – acute stressor, inadequate drug therapy, drug

tolerance

Cholinergic Crisis

Paradoxical weakness +/- cholinergic symptoms from

excessive AchE-inhibitor medication

Rare w standard doses of Pyridostigmine (< 120 mg Q3)

Tensilon Testing - Controversial

Edrophonium (Tensilon) - short-acting AchE-inhibitor

2 mg slow IV:

if muscle weakness clearly improves within minutes = likely Myasthenic Respiratory Crisis

Neurology > Neostigmine +/- Intubation, PLEX or IVIG

if patient gets visibly worse = Cholinergic Crisis

Atropine +/- Intubation

Warning:

Be ready to intubate before pushing

http://journals.lww.com/continuum/pages/videogallery.aspx?videoId=124&autoPlay=true

Recap

1. Steroids for Bell’s; Valacyclovir maybe

2. *HINTS exam on appropriate patients

3. Myasthenic respiratory crisis vs Cholingergic crisis

Sources

Evidence-Based Guideline Update: Steroids And Antivirals For Bell Palsy: Report Of The Guideline Development Subcommittee Of The American Academy Of Neurology. Neurology. 2012;79(22):2209-2213.

Early Treatment with Prednisolone or Acyclovir in Bell's Palsy. Frank M. Sullivan, Ph.D., Iain R.C. Swan, M.D., Peter T. Donnan, Ph.D. et al; N Engl J Med 2007; 357:1598-1607October 18, 2007DOI: 10.1056/NEJMoa072006

Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter, randomized, placebo-controlledstudy. Hato et al; Otol Neurotol. 2007 Apr;28(3):408-13.

HINTS to Diagnose Stroke in the Acute Vestibular Syndrome; Jorge C. Kattan et al; Stroke. 2009; 40: 3504-3510

Vertigo; Critical Decisions in Emergency Medicine volume 28; Jason Ondrejka, DO, and Francis R. Mencl, MD, MS, FACEP

Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e; Judith E. Tintinalli et al

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