 The rest of the story, I used to always listen to Paul Harvey when I was driving in a tractor. Who knows who Paul Harvey is? Anyone here to Paul Harvey? Yeah, I grew up in there. You learn the rest of the story. It's like a radio thing. Young children might not know about it. All right, so I wanted to, we were just going to walk through the rest of kind of like Adam said, applied anatomy in terms of the different, where different lesions can occur and how that then may manifest a little bit. So this first one is, Adam kind of hit on quite clearly. But again, if it's a super nuclear palsy and this is really important when you're evaluating any patient that you expect has a Bell's palsy, you really have to make sure that it does in fact involve the superior part of the face. Because if it's sparing the superior part, then your differential is quite significantly different. And you probably need to be sending that patient potentially for a stroke workup or some other workup to evaluate their CMS anatomy just to make sure that they don't have a mass lesion or anything else. Like he said, you get contralateral paralysis, volitional movements only of the lower face. And as we were just mentioning, particularly spontaneous blinking, but other emotional reflexes are usually preserved. The one thing that I didn't put in here between super nuclear palsy and brainstem lesions would probably be worth mentioning is, like Adam said, there is basal ganglia input to the seventh nerve. And so that's why, particularly with disorders that potentially affect the basal ganglia and Parkinson's super nuclear palsy, or progressive super nuclear palsy, you'll oftentimes see that they'll have a decreased blink rate as well, which is thought to be potentially related to input from that. In terms of brainstem lesions, like he mentioned, the cranial nerve nuclei is in the ponds. And so this usually will be at both upper and lower face lesion. It can be similar in appearance to your classic sort of Bell's palsy appearance in terms of the seventh nerve portion, but there often is going to be the associated sixth nerve pathology as well. And so, again, just once again reiterating important things when you're evaluating common things being common, probably the most common thing you'll see is a Bell's palsy. But you have to evaluate the other cranial nerves to make sure that you're not missing some sort of brainstem complex where you have multiple cranial nerves. You could also see multiple cranial nerve pathology if you have some trauma or inflammatory process in the temporal bone as well. So it's just important to make sure you're thinking about those things. Another really common anatomical area, so as the seventh nerve emerges from the brainstem at the CPA angle, oftentimes there can be lesions or masses at that point. And so a number of the associated symptoms are all related to the anatomy of what, like Adam said, the seventh nerve provides. So decreased hearing because of the parasympathetic, loss of salivary secretion again because of the parasympathetics, loss of taste from the anterior two-thirds of the tongue, which is something that I have to say, I don't think I've ever tested on my Bell's palsy patients, but like vinegar on the front of their tongue or anything. But they should have that symptom as well. Hearing impairment oftentimes because of its location and proximity to the eighth nerve and then may have an astagnous vertigo and ataxia. So we'll move on to the peripheral lesions. We'll save Bell's for last because it's most common but it's idiopathic. So trauma can oftentimes be a cause. Most commonly this is damage to the temporal bone and a lot of times there'll be other associated symptoms. Sort of in OCAPS mode, a highly testable one would be battle signs. So bruising over the mastoid bone or a patient who has blood in their middle ear. Oftentimes that can be a sign that they've potentially had a temporal bone fracture. So things to be considerate of. They may also have a delayed or incomplete paralysis because the nerve is sort of contused or there's swelling that's putting pressure on it. If you have a patient that has trauma and has a complete paralysis then you have to be concerned that they may be actually transected the nerve and then their outcome is unfortunately going to be quite significantly worse in that case. Ramsey Hunt. How many people have seen Ramsey Hunt just out of curiosity? Yeah. So just importance, again when you're... That's an important setting to look for. I mean if you're being called to look for a Bell's palsy again it's really important to... If you should be looking in their ears but if not make sure someone is looking in their ears to make sure that they don't have any herpetic involvement. Usually the vesicular rash will be in the auditory canal and they oftentimes will present similar to a zoster elsewhere where they'll have pain first before they'll have the associated signs and symptoms of the vesicular rash. They may also have sensory neural hearing loss and dizziness as well. And obviously you treat with acyclovir. The basic science book sort of said they were indeterminate in terms of their thoughts and the use of prednisone in these cases. So for OCAPs they shouldn't probably be asking you about that but acyclovir is definitely new. And the prognosis for Ramsey Hunt in terms of recovery is a lot worse in Bell's palsy. Other infectious and inflammatory ideologies. So interestingly I suppose to diagnose anyone with Bell's palsy you have to legitimately convince yourself that a patient doesn't have any of these although usually in Salt Lake we're not ordering lime titers on people unless they have a travel history that might be consistent with that. And I think just a history of TB or HIV is less but again considerations to be made. OCAPs loves this malignant otitis externa. So they'll talk about you have this patient who's an elderly diabetic patient. They have this really hot red swollen ear and they have a seventh nerve palsy and if you're like me you're just like oh that's Ramsey Hunt. They have this red ear. But it's actually what they're oftentimes getting out is this and it's classically pseudomonas. So for what it's worth. I've never seen that but I haven't seen a lot of things. And then sarcoidosis usually an infiltrative process in the parotid gland. So as Adam mentioned as the facial nerve is emerging it will pass through the parotid gland. So any pathology whether it be infiltrative or tumor compressive lesion can affect the cranial nerve. Speaking of tumors. So acoustic neuromas would be at the CPA angle. Meningeoma anywhere along the tract but oftentimes can be associated in the temporal bone. Then glomus tumors and parotid gland tumors are kind of the four most classic tumors that are affecting. Has anyone seen Melkinson-Rosenthal syndrome? You may see it in Peeds. There's one patient that Dr. Hoffman has that has this that periodically comes in. You can't leave him too. Oh did you? Okay. So they get recurrent facial paralysis, chronic facial swelling and this lingua placato which is this furrowing of the tongue. And it's usually in children or early adolescents that they're presented. Finally Bill's palsy. So this is kind of probably the one that you've seen or followed the most. It's idiopathic facial nerve palsy which in theory you kind of have to rule out everything else. I think importantly since it's probably the most common thing is to have an idea about recovery because patients always want to know that. So looking at a couple different books but basic science gives a number of 85% will have complete recovery at two to three months. There's a couple places that say like 70% by six weeks but the basic science says 85% by two to three months will have complete recovery. 10% will have recurrence either ipsilateral or contralateral. So I think that's important to tell patients that you have every expectation that they should get better that they need to treat very aggressively with topical medications in the meantime to prevent complications during that time period. But they also need to have a realization that it might not go away. So poor prognostic factors, if they have complete paralysis at presentation if they have advanced age or impairment of lacrimation those can all be sort of have poor prognostic findings. And currently the treatment for your O caps if it's less than 72 hours systemic steroids plus or minus acyclovir so if you're asked on O caps probably your answer should be just systemic steroids only. The data according to the basic science book is sort of still out. So there's been some studies that say yes you should be treating with antivirals there's some studies that say no so for your O caps that's what I would focus on. I'm just curious Dr. Warner currently like if you see a Bell's palsy and if you were on like your neurology team or if you saw it here would you, if you saw it very early on would you typically start them on antivirals if there wasn't a contraindication? If it was me I would have it. But can you make sense? Bilateral cranial nerve 7 deficit. So if it's a bilateral process and not a unilateral process and your differential maybe is a little bit different. So obviously if it's congenital in a kid that's a little different presentation but Mobius syndrome is sort of classically the syndrome that you'll find with that. Any infiltrative process so sarcoidosis oftentimes can cause bilateral infiltrative seventh nerve palsy from invasion of the protagland. Guillain-Barre syndrome like with a Miller-Fisher variant can present as a bilateral seventh nerve palsy and then bilateral acoustic neuromas and basilar meningitis. So obviously with a number of those they would have other associated neurologic symptoms as well. Facial innervation so this is commonly seen in patients who've had a seventh nerve palsy and maybe had complete or incomplete recovery. Oftentimes incomplete recovery. So kind of the two things that you'll hear about the Marcus Gunn jaw winking which is where when the patient is chewing and activating their fifth cranial nerve they'll have re-intervation to their orbicularis and will be blinking when they chew. And then similarly you hear about these crocodile tears which is again when the patient is sometimes can be with their chewing or other activation of the fifth nerve usually they'll have tearing as well. And then the other the last sort of area worth discussing on the seventh nerve in terms of clinical anatomy is the overactivity syndrome. So the first of these and probably the most common is benign essential blepharoplasm which certainly we see quite frequently in Dr. Crumb and Dr. Patel's clinic and then also in neuro-optimology. So it's an involuntary spasm of the orbicularis that's quite forceful. Interestingly you know if you've I've certainly seen these patients in neuro-optimology and they I mean they can be in essence sort of functionally blind from this if they just like cannot keep their eyes open enough to see. And so even though you may be able they may be able to read on the chart 2020 if you actually get them to relax and other things if they're in spasm all the time they really can't visually function very well. So typically absent during sleep more common in female and then most common treatment at this point Botox you'll hear about people doing orbicularis myomectomy. So Dr. Anderson here in town was actually I think one of the primary people who described that technique first we're actually removing some of the orbicularis. A lot. A lot. Yeah correct. So they have a lot then kind of similar problems where they have difficulty closing and then get into problems with that as well. So Dr. Patel is not a fan of that procedure. The other sort of three overactivity syndrome. So hemifacial spasm is usually a unilateral process for a long time or for a while was sort of thought to be like benign essential blood for a spasm with not really having a great ideology. Now it's thought to be secondary to compression of the seventh nerve typically at the brain stem oftentimes this is present during sleep. And then facial and eyelid myokymia. So if you've ever been stressed you maybe have experienced eyelid myokymia. It's a benign fasciculation or sort of tremor of your orbicularis. Patients will sometimes call in and be super nervous about it. Usually not an issue. Facial myokymia does have more associated syndromes. So particularly if you have a multifocal or progressive facial myokymia meaning it involves the entire side of the face you want to be considering MS or also gliomas can cause that as well. So questions. Be honest with your answers. Give you a minute. Good. Ashley, you got any? Sir, I'm going to end you. Good. Anyone else? What's up? Yep. Yep. Perfect. And then basilar meningitis. That's right. According to the basic clinical science, what percentage of patients with Bell's palsy usually recover seventh nerve function? Julia, what's your guess? What was it? 85%. 85%, good job. And finally, which of the following has felt to be most likely secondary vascular compression of the seventh nerve at the brain stem? One of these overactivity. Way to go. You guys are doing awesome. That's it.