A 39-year-old woman presented with right facial weakness and blurry right eye vision. On examination, she had right facial droop and inability to fully raise her right eyebrow or wrinkle her forehead. She was diagnosed with Bell's palsy. Steroids are recommended for treatment as they improve recovery rates. The addition of antivirals may provide additional benefit for severe cases.

2. 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?

3. Bell’s Palsy!

4. 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…

5. 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

6. 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!

7. 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?

8. Peripheral Vertigo!

9. Critical Approach
Step 1: Is this true vertigo?
Step 2: If so, is it Peripheral or Central
vertigo?

10. 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

11. 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

12. 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!

13. 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

14. Only use on appropriate patients!
- Not BPPV
- Low risk…

15. HINTS Exam
 Nystagmus
 HINTS exam c/w Peripheral Vertigo:
 https://www.youtube.com/watch?v=Wh2ojfgbC3I (HI)
 http://journals.lww.com/continuum/pages/videogallery.as
px?videoId=3&autoPlay=true (N)
 http://journals.lww.com/continuum/pages/videogallery.as
px?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)

16. 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

17. 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?

18. Myasthenia Gravis!
Myasthenic
Respiratory Crisis
OR
Cholinergic Crisis
(that is the question!)

19. 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

20. 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

21. Cholinergic Crisis
 Paradoxical weakness +/- cholinergic symptoms from
excessive AchE-inhibitor medication
 Rare w standard doses of Pyridostigmine (< 120 mg Q3)

22. 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

23. Recap
1. Steroids for Bell’s; Valacyclovir maybe
2. *HINTS exam on appropriate patients
3. Myasthenic respiratory crisis vs Cholingergic crisis

24. 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-controlled
study. 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
UpToDate.com
Emcrit.org