hi today we're going to talk about neurological disorders including bell's palsy vertigo and trigeminal neuralgia so let's begin bell's palsy is an acute unilateral weakness or paralysis of the facial nerve it usually starts and progresses to full paralysis within 72 hours and has an unknown ideologist etiology excuse me bell's palsy is the most diagnosed facial nerve condition all age groups may be affected however is most common in young and middle-aged adults and is pretty evenly distributed between men and women the cranial nerve typically affected as cranial nerve number seven symptoms typically go into remission within three months for most clients it is believed that bell's palsy is related to a viral illness and can be triggered by an infection or cold you can see an example of the presentation in the picture on the screen as stated before bell's policy has a typical onset that is acute and progressive the maximum level of facial paralysis occurs between 48 and 72 hours in most cases clients usually report pain behind the ear preceding the facial paralysis but in one to two days you will find that they have a four smooth forehead they cannot close their eye and they have an asymmetric smile you might also find tearing drooling post auricular pain tinnitus or mild hearing deficits timing of the onset is key in making a diagnosis if the symptoms are slowly progressive or relapsing it could suggest that this another disorder you want to take careful history when evaluating these clients in addition to the physical exam oftentimes the clients will report a recent history of infection or the presence of chronic illnesses like diabetes hypertension or hypothyroidism it is important to complete a thorough physical and neurological exam to rule out more serious nervous system condition like a stroke tumor or multiple sclerosis for diagnostics we don't typically obtain laboratory testing or imaging diagnosis is based on ruling out other potential causes if the client presents in an atypical fashion though you might obtain a line tighter in particular for those who had a tick exposure or an mri to view the entire facial nerve some important differentials to consider include a stroke multiple sclerosis and infection in particular lyme disease or a history of guillain-barre you can determine the diagnosis based on the rule out ruling out of other differentials in their history often the client will need a repeat visit to confirm diagnosis upon the paralysis resolution now let's talk about management and potential complications that you might find with bill's palsy non-pharmacologic management involves eye protection and is in consideration for surgical decompression protection of the eye is the most important goal for patients with bell's palsy and incomplete eye closure a potential complication from not protecting the eye would be exposure keratitis and it can result in blindness so it's very important to have the client protect the eye protect the eye in particular the cornea from abrasion and dust you should recommend protective glasses moisturizing eye drops and potentially closing and taping the eyelids at night only consider surgical decompression of the facial nerve in cases that have continual recurrence and pain that is significant physical therapy might also be beneficial for facial muscle weakness poor from for pharmacologic management our primary goal is to decrease inflammation and this can typically be accomplished using steroids or corticosteroids per your text corticosteroids can help more than 75 percent of patients recover with some nerve function when given within the first three weeks you want to be sure to start bell's palsy clients um on cortical steroids within this first 72 hours of symptoms there may be a small added effect when corticosteroids are coupled with antiviral administration antiviral administration alone has not shown to have benefit for treating bell's palsy pain that occurs with bell's palsy can be treated with acetaminophen or a non-steroidal anti-inflammatory drug you should consider potentials for complication and disorder and don't forget that eye protection is our priority so that we can avoid keratitis you want to include teaching where patients will recognize and notify the provider of symptoms like increased pain discharge or draining of the eye and symptoms that recur or worsen one important complication of not protecting the cornea accurately is having a corneal ulceration also hearing loss permanent tinnitus and poor recovery and facial symmetry can also be complications that are long-standing from bill's policy you may consider consulting a neurologist if symptoms fail to resolve within four to six weeks or there are other cranial nerve involvements that are present vertigo is the illusion of the environment or ourselves rotating or spinning or tilting or even a sensation that one is going to fall down vertigo can be classified as central or peripheral it affects approximately five to ten percent of the general population and is more common in clients older than 40 years of age typically vertigo presents as dizziness but clients can also report nausea vomiting tinnitus ear fullness or hearing loss the diagnostic tests necessarily really depend on the differentials so let's talk about some potential differentials first and then we'll spend a little time on diagnostics potential differentials include vascular insufficiency stroke neoplasm migraines multiple sclerosis seizures meniere's disease labyrinthitis and bppv also known as benign paroxysmal positional vertigo when you are doing or collecting your patient history it is important to determine if the onset and duration is recurrent or new in acute vertigo it is usually new and seen with ear infections vestibular neuritis multiple sclerosis and labyrinthitis recurrent vertigo is seen with bppv motion sickness and meniere's disease you want to ask the client to describe their symptoms with words other than dizzy you also want to be careful to note any triggering or alleviating factors equally important to determining diet is diagnostic testing is determining if the client has had any previous testing like audiometric testing a ct scan or mri it's also important in looking at the differentials that you include the physical examination and evaluating the client's gait and their cranial nerves if the client has had head trauma collecting a ct scan will be important if you suspect a mass in the brain you should collect an mri a client if the client is reporting hearing loss an audiogram will be needed and you will perform a lumbar function to rule out meningitis determining which diagnostic test to use is directly related to what evidence you find from your history and your physical exam management of vertigo depends on which type the client might have you might utilize non-pharmacologic or non-or pharmacologic techniques or physical therapy for non-pharmacologic management it typically involves bed rest for acute phases or episodes of bppv for chronic vertigo pt for vestibular rehab might be important in meniere's disease it is helpful to also include nutritional therapy that would instrict excuse me restrict sodium caffeine alcohol and tobacco in addition to bed rest although bpbv clients benefit from bed risk you might also consider a catalyst procedure also known as a crp or an empathy procedure for pharmacologic treatment you will consider antihistamines like mechazine or dramamine or benzodiazepines like valium or diazepam or beta adrenergic antagonists like ephedrine or anti-cholinergic agents like scopolamine patches diuretics might be helpful in treatment of meniere's disease as well there are some special population considerations that you should make in pediatrics the most common cause of dizziness is otitis media migraines and bppv in geriatrics normal aging affects degenerates the neural structures that maintain balance and performance in equilibrium disequilibrium can be a common complaint from them and vestibular disorders account for about half of dizziness that is reported it is common for vertigo to have root causes from a different disorder the american academy of oral or torah land geology i'm probably messing that up but at any rate that academy does not recommend the use of vestibular suppressive medication when treating bpbv you should consider consultation to a physician if a client has not improved in two to four weeks you also should consider referral to an oral laryngologist if you think the client requires audiometric testing or eng for balance and other test balance testing trigeminal neuralgia is a well-defined oral facial pain disorder restricted to the sensory branches of the trigeminal nerve it is a pretty painful disorder that causes spasms and pain lasting seconds to minutes the pain is typically described as burning or stabbing sharp penetrating or like an electric shock to the jaw the pain typically occurs on one side of the face and pain may reoccur once a month or several times per day when a client is having an attack they may stop talking stop chewing rub or pinch their face grimace or maybe make movements of the face or jaw and on exam you might find a trigger zone trigger zones are considered small areas of the skin or in the oral mucosa that the patient can identify as points that set off an attack typically trigger points are generally in the distribution of the nerve branch that's experienced in the pain in addition to a careful history you should be certain to examine all cranial nerves in detail diagnosis is usually made based on the patient history and physical findings and there are no essential diagnostic procedures that will need to be completed you would only attain diagnostics if you are also ruling out potential differentials speaking of differentials some you might include are headache migraine tuber aneurysm chronic meningitis or neuralgias or even dental abnormalities trigeminal neuralgia can also be a common cause of pain and multiple sclerosis so if the client is also demonstrating some signs and symptoms of multiple sclerosis you may include that in the differentials list then you can further differentiate your diagnosis to either classic trigeminal neuralgia or idiopathic trigeminal neuralgia idiopathic trigeminal neuralgia may be diagnosed when there is no lesion or other disease that could cause the problem classic or also known as secondary trigeminal neuralgia can be diagnosed through mri or mra imaging that would show compression of cranial nerve five root management of trigeminal neuralgia is mainly pharmacology patients who do not tolerate medications or fail in pharmacologic management with three medications might need referral to a neurosurgeon for surgical assessment some clients also find help and comfort in some complementary and alternative medications like acupuncture nutritional therapy or botox otherwise when using a pharmacological approach you should prescribe in a stepwise fashion the first line drugs should include anti-convulsants if the patient does not respond well to a first line then you may either switch to a second line drug or add a second line treatment to your first line that is already prescribed if the patient does not respond satisfactorily to two combination drug therapy then you may add an additional second line drug if the client has been diagnosed with ms then you should consider using gabapentin for treatment when clients are having acute episodes with in retractable pain sumatran may be utilized and also injections of botox have been considered as a promising medication approach with some small studies and positive results there aren't typically many complications for trigeminal neuralgia but when there are complications they are from pharmacologic management so when you are prescribing consider the age and or comorbidities and side effects of the drug therapy be sure to provide client education regarding medication therapies because all of them do create some level of sedation if you have questions please head on over to the discussion board or shoot me an email and i'll be happy to try to help you