1. Most prescribe steroids. The benefit is controversial. Conversely, 60mg of Prednisone for 7-10 days has only minor risks.
   
   
2. The prognosis is so poor for Herpes Zoster Oticus cases that specialty consultation is required for patient satisfaction (that all possible was done) and for the PCP's medical legal protection.
   
   
3. Possible Lyme disease in endemic areas.

Overview of Facial Paralysis

One must begin with the statement that Ònot all that does not move is Bell's." Bell's palsy properly known as "idiopathic facial paralysis," is by far the most common cause of facial paralysis, but it is a diagnosis of exclusion. Some of the causes of facial paralysis such as trauma are obvious, but others such as neoplasms are as commonly missed as they are diagnosed.

Certainly, a good ENT exam will include palpation of the parotid and an examination of the ear, looking for chronic otitis media or other abnormality. There are those that believe that most Bell's palsy is caused by a Herpes virus, and that the appropriate treatment is prednisone, usually 60 mgs a day for 5-7 days, followed by 3 days of 40 mgs and 3 days of 20 mgs. Those who believe it is herpetic, will treat with acyclovir or one of the other antiviral medications.

A thorough head and neck exam, including cranial nerves is always required. Herpes zoster can present similarly, has a poor prognosis and must be treated aggressively with antiviral agents. Multiple cranial nerve involvement speaks for herpes infection and argues for antiviral therapy.

Trigeminal nerve defects, particularly the corneal division of the first branch, suggests a cerebellopontine angle tumor. It is very important to have documented the patient's neurologic status at the time of initial presentation.

The most dangerous, immediate issue is corneal desiccation. In facial paralysis, the eyes do not close and particularly in individuals with a poor Bell's phenomenon, the eye is at great risk for desiccation. If this is not picked up and treated immediately, the cornea can be lost and the patient left blind.

Tears Natural^R or some other wetting agent can be prescribed through the day. The night time hours are the most difficult. The obvious solution would be to fill the eye with Lacrilube. This unfortunately leaves one with a blurry vision and some do not care for it. Alternate therapy is complex. Some tape the eyelid shut. This is fine when it works, but, per chance the eye opens, and the tape or gauze comes in contact with the cornea, corneal abrasions may ensue. Other treatments involve creating moisture chambers. These involve taping a plastic material such as saran wrap around the orbit in such a way that the eyeÕs own moisture is retained.

All patientÕs with Bell's Palsey recover, it is only a matter of degree. Most improvement is made during the first three months, with the majority regaining 80% of facial nerve function. If a complete paralysis persists at 3 months, the patient did not have Bell's Palsy. An ENT referral and an evaluation for other causes, is now required.

Lastly, Lyme disease can present with cranial nerve neuropathies. If there is reason to suspect the illness, a workup should begin.