Refusal to Use an Upper Extremity in a 17-month-old with Facial Nerve Palsy

摘要

A 17-month-old girl presents to the pediatric emergency department for evaluation of right-sided facial palsy and decreased movement of her right arm. One week before presentation she was evaluated for acute onset of left eye redness, left-sided facial swelling, and a low-grade fever for 1 day. Her left tympanic membrane was described as dusky and slightly erythematous. Early acute otitis media was diagnosed, and amoxicillin therapy was started. Two days later her primary care physician evaluated her for persistent facial swelling despite antibiotic therapy. Her tympanic membranes appeared normal then and her neurologic examination was significant for facial nerve palsy with inability to close the right eye, incomplete raising of the right eyebrow, and drooping of the right side of the mouth. She was diagnosed as having Bell’s palsy. Amoxicillin was discontinued, and acyclovir (20 mg/kg 3 times daily) and prednisolone (1 mg/kg once daily) were started. The parents now report that the patient is crying inconsolably and no longer using her right arm. On presentation she is febrile (rectal temperature, 102.4°F [39.1°C]), and her neurologic examination is notable for complete right-sided facial nerve paralysis with asynchronous blink, minimal forehead muscle movement, flattened nasolabial fold, and right-sided partial paralysis of the mouth. Muscle bulk and tone are normal throughout, but she demonstrates decreased spontaneous movement of the right arm at the shoulder joint. With distractibility, there is no point tenderness to palpation of the right arm. She can withdraw with distal painful stimulation. She moves briefly against gravity at the elbow joint.