Misdiagnosis of Bell's palsy: Case series and literature rev
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A 50 year-old female with no ocular history and a medical history of diabetes mellitus presented to the oculoplastic service for management of right eye lagophthalmos due to Bell's palsy. The patient reported that 4 months prior to presentation her right face became swollen and painful following a tooth extraction. This facial swelling was attributed to a dental abscess, and she went on to require intensive care unit (ICU) level care at an outside hospital for cellulitis in the setting of diabetic ketoacidosis.

Her swelling resolved with antibiotic therapy, and she followed with her primary medical doctor for the next four months for persistent complaint of right?sided facial pain and weakness. Concurrently, she was followed by an ophthalmologist (three visits) for difficulty closing her right eye. Lagophthalmos and corneal exposure with inferior corneal scarring were noted but neither the patient's visual acuity nor the function of cranial nerves other than the facial nerve were documented at these ophthalmologic evaluations. Both providers documented concern for “Bell's Palsy,” and the patient was treated with oral corticosteroids. After 4 months, her medical doctor recommended neuroimaging (MRI) but she was referred to oculoplastics for further management of her persistent lagophthalmos prior to obtaining this study.

On presentation, she had no light perception visual acuity in the right eye. Her examination was also significant for House-Brackmann grade 4 palsy of the right facial nerve and loss of sensation in the V1 distribution of the right trigeminal nerve. The severity of keratopathy limited posterior examination, but the right optic nerve appeared pallid. Further workup was performed, and a dedicated MRI of the orbit with and without gadolinium contrast demonstrated optic nerve atrophy, abnormal enhancement along the trigeminal nerve with extension to Meckel's cave, and edema of the right temporal lobe concerning for perineural spread and cerebral parenchymal involvement of an invasive malignancy.

Subsequent transnasal endoscopic biopsy of the pterygopalatine fossa demonstrated fungal elements which were identified as Mucorales species, and she was diagnosed with chronic mucormycosis of the right muscles of mastication and skull base. She was treated with amphotericin and micafungin and has remained symptomatically and radiographically stable in follow up for over two years.

Source: https://onlinelibrary.wiley.com/doi/10.1002/ccr3.2832
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