Facial Droop

Etiology Uncertain (i.e. Bell’s Palsy):

  • Start valacyclovir 1000 mg TID x 1 week + prednisone 60 mg qd x 1 week

  • Continue work-up per clinical suspicion (see differential diagnosis)

  • Counsel patient that symptoms improvement within 21 days indicates a favorable prognosis

Differential Diagnosis

  • Neurologic

    • Stroke (spares forehead)

    • Tumor (in order of prevalence)

      • Metastatic: Most commonly originate from lung or breast cancer

      • Meningioma: Benign tumor arising from the meninges that may result in mass effect

      • Glioblastoma: Most common primary tumor (15,000 cases/year) with 50% mortality rate at ~ 1 year

      • Astrocytoma: Variable aggressiveness and treatment with resection +/- chemotherapy, radiation

  • Infectious

  • Autoimmune

    • Sjogren syndrome

      • Dry eyes, dry mouth, parotid gland enlargement, abnormal dental caries

      • Positive Schirmer test, rheumatoid factor, anti-Ro/SSA and/or anti-La/SSB antibodies

      • Refer to rheumatology, ophthalmology, dentistry

    • Sarcoidosis

    • Guillain-Barre syndrome (see WHO Brighton Criteria)

      • Progressing symmetric muscle weakness and decreased/absent deep tendon reflexes over two weeks

      • Lumbar puncture (initial): Increased protein with normal WBC count (< 50 cells/ul)

      • EMG (confirmatory): Decreased motor nerve conduction velocity, prolonged distal motor latency, increased F wave latency, dudution blocks, and temporal dispersion that return to baseline after 2 weeks