Potential Misdiagnoses of Bell's Palsy in the Emergency Department

Abstract

Study Objective We evaluate the incidence of potentially incorrect emergency department (ED) diagnoses of Bell’s palsy and identify factors associated with identification of a serious alternative diagnosis on follow-up. Methods We performed a retrospective cohort study from California’s Office of Statewide Health Planning and Development (OSHPD) for 2005–2011. Subjects were adult patients discharged from the ED with a diagnosis of Bell’s palsy. Information related to demographics, imaging use, and comorbidities were collected. Our outcome was one of the following diagnoses made within 90 days of the index ED visit: stroke, intracranial hemorrhage, subarachnoid hemorrhage, brain tumor, central nervous system infection, Guillain-Barre syndrome (GBS), Lyme disease, otitis media/mastoiditis, or herpes zoster. We report hazard ratios (HR) and 95% confidence intervals (CI) for factors associated with misdiagnosis. Results A total of 43,979 patients were discharged with a diagnosis of Bell’s palsy. Median age was 45. On 90-day follow-up 356 patients (0.8%) received an outcome diagnosis, and 39.9% were made within 7 days. Factors associated with the outcome included increasing age (HR 1.11, 95% CI 1.01–1.21, every 10 years), black race (HR 1.68, 95% CI 1.13–2.48), diabetes (HR 1.46, 95% CI 1.10–1.95), computed tomography or magnetic resonance imaging use (HR 1.43, 95% CI 1.10–1.85). Private insurance was negatively associated with an alternative diagnosis (HR 0.65, 95% CI 0.46–0.93). Stroke, herpes zoster, GBS, and otitis media accounted for 85.4% of all alternative diagnoses. Conclusion Emergency providers have a very low rate of misdiagnosing Bell’s palsy. The association between imaging use and misdiagnosis is likely confounded by patient acuity. Increasing age and diabetes are modest risk factors for misdiagnosis.

Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data

“…SPADE has been used for other symptoms and signs tied to missed stroke (headache-aneurysmal subarachnoid haemorrhage 19 ; facial weakness-ischaemic stroke 35 ); to missed cardiovascular events (eg, chest pain-MI) 2024 ; and to missed infections (eg, fever-men-ingitis/sepsis 36 ; Bell’s palsy-acute otitis 35 ). Since missed vascular events and infections together account for at least one-third of all misdiagnosis-related harms, 37–40 using SPADE to monitor and track such errors would represent a major advance for the field.…”

“…Most prior studies using aspects of the SPADE approach have examined data sets containing 20 000–190 000 visits to identify misdiagnosis-related harm rates of ~0.2%–2%. 212535 From a statistical standpoint, the total number of diagnostic error-related outcome events (eg, admissions) should ideally not be fewer than 50–100, so this implies minimal sample sizes of 5000–50 000 visits for event rates in the 0.2%–2% range. Thus, even for common symptoms or diseases, data must generally be drawn from a large health system or region over a short period (eg, 6 months) or a small health system or hospital over a longer period (eg, 5 years).…”

A Rare Cause of Facial Paralysis in Children: A Case of Ramsay Hunt Syndrome

“…Conditions that may present with facial paralysis include RHS, stroke, Guillain-Barré syndrome, Lyme disease, multiple sclerosis, human immunodeficiency virus infection, otitis media, diabetes mellitus, sarcoidosis, Bell's palsy, trauma to the facial nerve, autoimmune diseases such as Sjogren's syndrome, lymphoma, cerebellopontine tumors, meningitis, and metabolic disorders. 5,6 VZV reactivation may rarely present with facial paralysis and an increase of VZV antibodies in the absence of a typical vesicular rash, known as zoster sine herpete variant. 7 The incidence of VZV reactivation has been reported to be higher in children aged 6 to 15 years than in younger children.…”

Evaluation of Societal Health Utility of Facial Palsy and Facial Reanimation

“…The chosen years of life remaining (ie, 36 years) correlated with the mean life expectancy (approximately 80 years) from the median age of Bell palsy onset (45 years) 31 and from the mean age at first presentation to our center (44 years) of patients with various etiologies of facial palsy. 32 For SG and TTO, a 6-level iterative ping-pong approach with pictorial cues was used.…”