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

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a case of cva in the rvh er

A case of CVA in the RVH ER…

Chenjie Xia (PGY-3)

AHD Interactive Case

Wednesday, Feb. 23rd, 2011

on call at the rvh
On call at the RVH…
  • RVH ER page at 9:30PM
  • Code purple, please see stroke patient for admission…
patient background
Patient Background
  • ID: 74M, right handed
  • RFC: stroke
  • Social history: Chinese origin, retired real estate agent, lives with wife
patient background1
Patient Background
  • PMHx:
    • HCC with cirrhosis
      • 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 background2
Patient Background
  • Meds
    • 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
History
  • Woke up this AM and notes new right facial weakness, i.e. right mouth droop
more 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 history1
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
differential diagnosis
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
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
more exam findings
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)
muscles innervated by 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 findings1
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
differential diagnosis1
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 diagnosis2
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
Findings

CT head: old left putamen lacune, nil acute

question
Question
  • Does the decreased taste favor Bell’s palsy or facial nerve injury secondary to parotid lesion?
slide26

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

question1
Question
  • Can you name the 4 functional categories of the facial nerve and briefly describe what they do?
answer
Answer
  • 1) Branchial motor
    • 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
question2
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
branchial motor1
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
parasympathetic 1
Superior salivatory nucleus

GT petrosal nerve leaves genu

Reach the sphenopalatine ganglion

post-ganglionic fibers  lacrimal glands

Parasympathetic (1)
parasympathetic 11
Superior salivatory nucleus

GT petrosal nerve leaves genu

Reach the sphenopalatine ganglion

post-ganglionic fibers  lacrimal glands

Parasympathetic (1)
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)
parasympathetic 21
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)
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)
visceral sensory special1
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)
f u imaging
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
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