What is the emergency medicine workup for a patient presenting with face spasms?

Emergency Medicine Workup for Facial Spasms

The emergency medicine workup for facial spasms should focus on ruling out serious causes like stroke, Bell's palsy, and other neurological conditions through targeted history, examination, and selective diagnostic testing.

Initial Assessment

• Determine the onset, duration, and progression of facial spasms - sudden onset suggests Bell's palsy or stroke, while gradual onset may indicate other conditions 1
• Assess for unilateral vs. bilateral involvement - unilateral symptoms are more common in Bell's palsy (70% of facial nerve palsies) and hemifacial spasm 1, 2
• Document the specific pattern of facial movement - involuntary, irregular clonic or tonic movements suggest hemifacial spasm, while weakness/paralysis suggests Bell's palsy 2
• Evaluate for associated symptoms that suggest alternative diagnoses:
  • Dizziness, dysphagia, or diplopia suggest diagnoses other than Bell's palsy 1
  • Hyperacusis may be present in Bell's palsy 1

Focused Physical Examination

• Perform a complete cranial nerve examination, especially focusing on:
  • Facial nerve (CN VII) function using the House-Brackmann scale 1
  • Eye closure and facial symmetry 1
• Apply the Cincinnati Prehospital Stroke Scale (CPSS) to rule out stroke 1:
  • Facial droop - have patient show teeth or smile
  • Arm drift - have patient close eyes and hold both arms out
  • Speech abnormalities - have patient repeat a standard phrase
• Check for other neurological signs that may indicate stroke or other serious conditions 1

Diagnostic Approach

• Do not routinely order laboratory tests for patients with typical presentation of Bell's palsy 1
• Do not routinely perform diagnostic imaging for patients with new-onset Bell's palsy with typical presentation 1
• Consider MRI with contrast in cases with:
  • Atypical presentation
  • Recurrent symptoms
  • Symptoms persisting beyond 2-4 months
  • Multiple cranial nerve involvement 1
• High-resolution thin-cut contrast-enhanced MRI is particularly useful when perineural tumor spread is suspected 1
• For hemifacial spasm, 3-D heavily T2-weighted MRI sequences and MRA can help characterize vascular loops potentially compressing the facial nerve 1

Differential Diagnosis

• Bell's palsy (idiopathic facial nerve palsy) - most common cause (70% of facial nerve palsies) 1
• Hemifacial spasm - typically caused by vascular compression of facial nerve 2
• Stroke - use CPSS to screen; if positive, immediate neuroimaging is indicated 1
• Secondary causes of facial spasms (19% of cases) 2:
  • Previous Bell's palsy
  • Facial nerve injury
  • Demyelinating conditions
  • Vascular insults
• Mimickers of hemifacial spasm (18% of cases) 2:
  • Psychogenic causes
  • Tics
  • Dystonia
  • Myoclonus
  • Hemimasticatory spasm

Management in the Emergency Department

• For Bell's palsy:
  • Prescribe oral steroids within 72 hours of symptom onset for patients 16 years and older 1
  • Do not prescribe oral antiviral therapy alone 1
  • Consider oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset 1
  • Implement eye protection for patients with impaired eye closure 1
• For laryngospasm (if present with facial spasms):
  • Apply continuous positive airway pressure with 100% oxygen 1
  • Consider Larson's maneuver - applying pressure at the "laryngospasm notch" 1
  • For persistent laryngospasm, consider propofol (1-2 mg/kg IV) 1

Disposition and Follow-up

• Arrange follow-up or referral to a facial nerve specialist for patients with 1:
  • New or worsening neurologic findings at any point
  • Ocular symptoms developing at any point
  • Incomplete facial recovery 3 months after initial symptom onset
• Inform patients that while facial spasms are usually a lifelong condition, there is approximately a 5% chance of long-term resolution 3

Pitfalls to Avoid

• Failing to distinguish between Bell's palsy (weakness/paralysis) and hemifacial spasm (involuntary movements) 2
• Missing stroke as a cause of facial weakness by not applying stroke screening tools 1
• Ordering unnecessary laboratory tests or imaging studies for typical presentations of Bell's palsy 1
• Delaying steroid treatment beyond 72 hours for Bell's palsy 1
• Failing to provide adequate eye protection for patients with impaired eye closure 1