HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Medical Management of Acute Facial Paralysis

Lyme disease is another infectious cause. It is caused by the spirochete Borrelia burgdorferi , which is transmitted to humans by ticks. Although named after a town in the northeast, it is present across the entire United States. The diagnosis requires a high level of suspicion, as patients often do not recall a tick bite or rash, and serology can demonstrate false negatives early in the course of disease. Bilateral FP may occur. Patients may also report fatigue and severe headache. The differentiation from BP or other viral-associated FP is important because steroids may be associated with worse prognosis and postparalytic synkinesis. 20 Diagnostic testing includes serum and ce- rebrospinal fluid testing for Borrelia antibodies. Corticosteroid monotherapy is thought to increase the spirochete load in neural tissues. Medical treatment follows current Centers for Disease Control and Prevention (CDC) guidelines ( https://www.cdc.gov/ lyme/ ). Antibiotics, such as doxycycline, cefuroxime, or amoxicillin, are prescribed for a 10-day to 21-day course. An antiviral (valacyclovir) may also be added because facial nerve inflammation may theoretically lead to viral reactivation. Adjuvant cortico- steroid therapy has not demonstrated benefit in Lyme disease–associated facial palsy and their role remains unclear. 20 Human immunodeficiency virus Human immunodeficiency virus (HIV)-related acute FP occurs during early or late- phase HIV infection. Patients may present with unilateral or bilateral FP. 21 In the early phase of the disease, the etiology of FP is similar to the general population and most likely related to BP. However, in the later stages, lymphoma and other secondary causes are more common. 22 Diagnostic testing includes HIV antigen and antibody tests. During seroconversion (early stages), treatment is similar to BP and corticoste- roid and antiviral therapy with/without antiretroviral therapy is used. Treatment for HIV follows current CDC guidelines ( www.cdc.gov/hiv/ ). Nonmalignant Otologic Disease Acute otitis media (AOM) and rarely cholesteatoma may result in acute FP. 23 In AOM, patients may present with otalgia, otorrhea, hearing loss, fever, and abnormal otoscopy findings. Broad-spectrum parenteral antibiotics and steroids should be given. Depend- ing on the case, myringotomy with or without mastoidectomy may be indicated. Initially broad-spectrum antibiotics are used and then refined based on the bacterial culture. Chronic otitis media causing FP is most likely due to cholesteatoma in 60% to 80% of cases. 24,25 Cholesteatoma is a nonneoplastic, keratinizing squamous lesion composed of a proliferation of epithelium and may be congenital or acquired. 26,27 In acquired cholesteatoma, one theory suggests that negative middle ear pressure causes a retraction pocket and trapped epithelial components. Secondary infection leads to accumulation of debris, immunogenic cells, and lytic enzymes. The enzymes contribute to osteolysis. Although pathologically nonmalignant, the lesion may be locally destructive. Patients commonly present with otalgia, otorrhea, and hearing loss. Three percent of patients with cholesteatoma may present with sudden or gradual FP. In this subset, most patients had acute FP, labyrinthitis, hearing loss, and bony destruction of the cranial fossa. The treatment of cholesteatoma is primarily surgical with adjuvant medical therapy (antibiotics and steroids). Surgical findings may include bony defects in the fallopian canal, bony labyrinth with exposure of the semi- circular canals and vestibule, and cranial base. 24

MALIGNANT OTITIS EXTERNA

Malignant otitis externa usually begins as an otitis externa of the external auditory canal. The infection progresses to an osteomyelitis of the temporal bone and the

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