Insect bite and arrows

Abstract

A 68 year old man was noted by his wife to have an “insect bite” on the pinna of his left ear. The lesion was red and swollen like a blister. The patient described shooting pains “like arrows” originating from his left ear and radiating over the top of his head. On the morning of presentation he was unable to close his left eye, and his wife noticed that the left corner of his mouth was drooping. Examination of the ear showed several crusted lesions and blisters in the left external acoustic meatus and pinna (fig 1). Fig 1 Left external acoustic meatus and pinna The patient was asked to close his eyes firmly and attempt to smile. Fig 2 shows that he was unable to close his left eye and the left side of his mouth remained motionless. While forcing his right eyelid shut against resistance, the left eye rolled upwards. When asked to raise his eyebrows, the left side remained motionless. Oral examination was normal. Fig 2 Unilateral facial palsy 1. Which sign is shown when the patient's eye rolls upwards? 2. What condition is this patient likely to have? 3. How should this patient be managed? 1. This is a positive Bell's sign (see discussion). 2. These signs and symptoms are pathognomonic of …