What is the workup for a woman presenting with subacute paresthesias in the face radiating down the neck and arm?

Workup for Subacute Facial Paresthesias Radiating to Neck and Arm in Women

A thorough neurological assessment with targeted diagnostic testing based on clinical suspicion is the recommended approach for women presenting with subacute paresthesias in the face radiating down the neck and arm, rather than routine laboratory or imaging studies. 1

Initial Clinical Assessment

Key History Elements

• Onset characteristics: sudden versus gradual progression
• Associated symptoms:
  • Dizziness, dysphagia, diplopia (suggesting diagnoses other than Bell's palsy)
  • Hyperacusis or viral prodrome (suggestive of Bell's palsy)
  • Headache or altered mental status (concerning for central causes)
  • Recent infections, trauma, or underlying medical conditions

Physical Examination Focus

• Complete cranial nerve assessment (all 12 nerves)
• Neurological examination including motor, sensory, and reflex testing
• Assessment for other focal neurological deficits
• Evaluation for signs of systemic disease

Diagnostic Testing Algorithm

First-Line Laboratory Testing (when clinically indicated)

• Complete blood count
• Electrolytes and renal function
• Random glucose or HbA1c
• Vitamin B12 levels 1

Targeted Laboratory Testing Based on Clinical Suspicion

• Lyme disease serology (in endemic areas or with supporting clinical features)
• Autoimmune markers if autoimmune etiology suspected
• Specific infection tests based on clinical presentation 1

Neuroimaging

• Not recommended routinely but indicated for:
  • Focal neurological deficits beyond isolated facial symptoms
  • Progressive symptoms
  • Associated headache or altered mental status
  • History of malignancy or immunocompromised state
  • Lack of improvement within 2-3 months 1, 2

Differential Diagnosis Considerations

Central Nervous System Causes

• Stroke or TIA
• Multiple sclerosis
• Brain tumors
• Inflammatory conditions

Peripheral Nervous System Causes

• Bell's palsy (accounts for approximately 70% of facial nerve palsies) 3, 1
• Lyme disease (Bannwarth Syndrome: meningitis, radiculitis, facial palsy) 4
• Entrapment syndromes
• Metabolic disturbances (diabetes)
• Connective tissue diseases
• Toxin exposure
• Nutritional deficiencies 5

Common Pitfalls and Caveats

1. Avoid premature closure: The erroneous use of "Bell's palsy" to refer to all causes of facial symptoms can lead to cognitive errors including premature closure and anchoring bias 2

2. Watch for red flags requiring further investigation:

   • Atypical presentation
   • Recurrent episodes
   • Additional neurological deficits
   • Lack of recovery within 2-3 months
   • History of head, neck, or cutaneous malignancy 2

3. Consider trigeminal trophic syndrome in cases with facial sensory symptoms, especially with skin changes or self-induced trauma 6

4. Recognize patterns of distribution: The specific pattern of paresthesia distribution (trigeminal, cervical dermatomes, brachial plexus) can provide important diagnostic clues 5, 6

By following this structured approach to evaluation, clinicians can effectively differentiate between idiopathic causes like Bell's palsy and more serious underlying conditions requiring specific treatment.