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Bell’s Palsy

Patty relates her story: “So I’m out for a nice dinner with my husband and it’s so embarrassing — as I’m drinking my water, it keeps dribbling out of the corner of my mouth.  At first I think I’m just being spastic and hope he didn’t notice.  But it keeps happening and I laugh and tell him my mouth doesn’t seem to be working right.  So he looks at me, and instead of laughing he suddenly looks scared and says, ‘C’mon we’ve got to get you to the hospital.’  What I didn’t know is that when I laughed, one side of my face moved normally and the other barely moved at all.  Of course he’s thinking, stroke!”

This account turned out, happily, to not be a stroke, but rather a condition called Bell’s palsy.  Of course, when in doubt it’s always best to get immediately to the ER and make sure it isn’t a stroke.  Bell’s palsy involves a loss of function of the facial nerve.  This is the nerve that triggers most of the movements of the muscles of the face.  So Bell’s palsy results in rapid paralysis or weakness of the facial muscles on one side of the face, usually progressing over up to 48 hours. The cause still hasn’t been totally nailed down.  It can happen at any age, but its peak prevalence is in 40-49 year olds.

When Bell’s palsy first strikes, it can be tough to distinguish from a stroke.  One clue is that with Bell’s palsy the forehead muscles on the paralyzed side don’t move.  So if you ask the person to raise their eyebrows or wrinkle their forehead, nothing happens on the paralyzed side.  On the other hand, when a stroke is the cause, the forehead muscles are usually spared and still move (wrinkle) on both sides – we won’t get into the whole reason for that, but it’s one way to help distinguish the two.

Along with the one-sided facial paralysis, Bell’s palsy may cause altered taste and loss of tear production on the affected side.  There also may be pain around the ear and sometimes vision is blurred on the affected side.

Treatment involves first making sure it’s Bell’s palsy and not a stroke.  If the symptoms aren’t clear-cut, a cat scan or MRI of the head may be done immediately since successful stroke treatment is often dependent on the timely use of clot-busting meds. If Bell’s palsy is diagnosed, steroids are the preferred treatment and antiviral agents may sometimes improve outcomes slightly as well.

The good news is that in 80-90% of cases, the symptoms slowly clear over a few months’ time.  In the meantime, the affected eye needs to be protected with frequent lubrication, and sometimes taped shut overnight to avoid drying out and damaging the cornea. Facial physical therapy is sometimes used but hasn’t really proved to make much of a difference in the rate of recovery. Various surgical procedures are used only rarely to aid eye closure in those cases where the paralysis proves permanent.

So, having Bell’s palsy certainly beats having a stroke, but it’s still no picnic.  It can sometimes be very slow to resolve, or rarely, may not ever fully recover.  If it strikes you or someone you love, and you’re not sure what it is, get to an ER and let them make sure it’s not a stroke.  Once you’re sure it’s Bell’s palsy they can help you to protect your eyes and give you meds that maximize your chances for a full recovery.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835






In Health, Silence Isn’t Always Golden

Most of us have heard the expression, “Silence is golden.”  The poet Thomas Carlyle, observed, “Silence is the element in which great things fashion themselves together; that at length they may emerge, full-formed… Silence is golden.”  But when it comes to our health, if those “great things fashion(ing) themselves” in silence to later “emerge, full-formed” are diseases, then silence isn’t so golden at all.  Why?  Because silent (asymptomatic) disease processes allow bad maladies to quietly sneak up on us without much warning.

            Let’s be more specific.  About two thirds of all deaths in the U.S. are attributed to just five causes: heart disease, cancer, chronic respiratory disease, accidents, and stroke. Most of these are the end result of silent processes that we don’t recognize until it’s too late.  The number one cause of death, heart disease, involves atherosclerosis, where plaque blocks the arteries that supply the heart.  When complete blockage of one of these occurs a heart attack often results.  That same process of atherosclerosis and artery blockage, when it involves arteries up in the brain, causes most strokes (the #5 cause of death) as well.  But until a heart attack or stroke hits, the process of blocking arteries is often silent, producing few or no symptoms.

            To go back a step further in the process, the factors that produce atherosclerosis, such as high blood pressure, elevated cholesterol, artery inflammation, and even early diabetes, also may bring little or no symptoms.  In fact, I occasionally wish some of these factors were routinely painful so that folks would be more motivated to treat them aggressively.

            What about cancer, the #2 cause of death?  Many types of cancer can grow for quite some time before any symptoms occur.  So screening tests, such as the wildly popular colonoscopy or mammograms or Pap smears are ways to discover cancers and pre-cancers while they are still curable.

            Even chronic lung disease (COPD, etc.), which is the #3 cause of death, can be mostly silent for a long time.  Because God builds a lot of reserve into lungs, folks can lose a substantial amount of lung function before they actually notice shortness of breath.  That’s where a simple in-office pulmonary function test can give a heads up before someone gets to a critical stage.  Sometimes that kind of information can help discover and define an otherwise stealthy process that, usually with the help of cigarette smoking, is slowly robbing breath from a person.

            I love it when my patients are aggressive with prevention; I would so much rather them be aggressive with preventing heart disease than with having to be aggressive in getting bypass surgery after a blockage finally shows itself with crushing chest pain. I’d rather they were aggressive in stroke prevention rather than having to be aggressive with rehab to try to be able to walk or speak again after a stroke.

            So what we’re saying is, so much of health is (often with the help of a trusted physician) discovering and controlling the silent processes that are going on inside us in order to prevent the big disasters.  If we wait until we can feel a problem, we’ve often waited too long.  So if it’s been a while, get a check-up that looks for and identifies these silent processes, because when it comes to our long term health, silence isn’t always golden.

Andrew Smith, MD is board-certified in Family Medicine and manages the Maryville office of Trinity Medical Associates located at 1503 East Lamar Alexander Parkway, Maryville.  He is accepting new patients with most commercial insurances and participates in Trinity’s Direct Primary Care program for patients who are without insurance, who belong to a cost sharing program, or who are Medicare beneficiaries.   Contact him at 982-0835


Medicine Expiration Dates – What Do They Mean?

As we went through Grandpa’s belongings after his passing one of the things we came upon were some carefully labeled but expired medicines.  And I don’t mean a couple of months expired; generally they had expired a decade or so ago.  Grandpa was always a frugal guy – cutting the mold off the cheese and eating the rest or grabbing and consuming the two-week-old casserole with a questionable odor before we could get it to the disposal.  So what about these expired meds?  Had his frugality in keeping these old prescriptions for later use posed any threat to him?  My bet is that almost all of us keep and take a few meds past their expiration date.  So just how risky is that?

In 1979 a law was passed requiring drug manufacturers to put an expiration date on their meds.  Up to this date the manufacturer guarantees the potency and safety of the medication.  So far so good, but how quickly do medicines lose their safety and efficacy after these expiration dates have passed?  Some years back, the Food and Drug Administration carried out a study to answer that question at the request of the military. The military had a large and expensive stockpile of drugs which they hated to just discard and replace every few years. The study was carried out on over 100 drugs, including both prescription and over-the-counter meds.  They found that more than 90% were both safe and effective even 15 years after their expiration date.

Ok, so for many medicines passing the expiration date doesn’t really mean the medication is no longer effective or is unsafe to use.  But are there exceptions to this?  One important exception is the EpiPen.  They have been in the news recently because of how crazy expensive they can be so there is a temptation to not refill them after the expiration date has passed.  Unfortunately a study done several years back found that the pens do in fact lose potency soon after passing their expiration date.  That means you really do need to keep your EpiPens up to date.  By the way, if somehow you find yourself treating a severe allergic reaction with an EpiPen and notice it’s expired, give it anyways (as long as it isn’t discolored and you can’t see particles in the fluid) since some potency is better than nothing.  But do this as you dial 911 or get immediate emergency care.  Other important exceptions would be nitroglycerin, insulin, liquid antibiotics, and aspirin.  Tetracycline may also be an exception although there is still debate about it.

So you’ll have to decide whether to take Grandpa’s approach and save almost everything or the other extreme of tossing everything the moment it hits its expiration date or some place in between.  For most meds, a little laxity with that stamped on expiration date is pretty reasonable.  Hey, Grandpa lived a healthy 90 years with his approach.

Andrew Smith, MD is board-certified in Family Medicine and manages the Trinity Medical Associates office at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835.  He is accepting new patients with commercial insurance in a typical fee-for-service model and those without insurance or with Medicare in a Direct Primary Care model.


Labors, Mercies and a Gift of Projection

When someone’s voice would rise above all the rest and be heard across the room, my wife’s family, the Davises, would remark knowingly, “He has the gift of projection.”  A little after nine in the morning a week ago Friday, a man who had, and I would say still has, the gift of projection, died in our home.  That man is my father-in-law, better known to most as “Grandpa”.

He passed into the next life at 91 years and 1 day old, or as he would have said it, 91 years, 9 months, and 1 day old.  When I say he had the gift of projection, I don’t mean that he spoke loudly, though he certainly could make himself heard.  What I mean is that his words projected an uncommon weight and influence.  They did so because, by the grace of God, they emanated from a life so well-lived.

A retired dairy farmer, Grandpa lived with us for some fifteen years. He tended to burst out of his room as if shot out of a cannon, ever on a mission.  At 90 years old he was still delivering meals-on-wheels to “the old folks”, staying active in church, keeping up with politics, quizzing us from the newspaper on where the highest and lowest temperatures in the country were, reading his Bible at length, praying for his 27 grandchildren and their parents, mowing the land on an old Massey Ferguson tractor, and working with the hands made large and strong by decades of working a dairy farm.

But I believe there was even more power in his words than in his hands; In the evenings Grandpa’s voice could be heard as he made daily calls to buoy old friends, encourage grandchildren on their birthdays or any other time he thought they might need it, and reconnect with a host of other people from a life lived stitching together warm human bonds.  He would meet strangers and inform us later that they were joining us for Thanksgiving dinner.  Four months ago he gave the toast at my second oldest daughter’s wedding.  His godly words were a centerpiece of the celebration.

But only a couple weeks later he emerged from his room limping badly with no remembrance of a fall – turned out to be a cracked hip.  That was the start of a steep three-month free fall, from limp, to cane, to walker, to wheelchair, to bed.  The hip would get better, but then other things would go bad.  This vigorous vibrant man suddenly grew weak, shrinking before our eyes until finally, even the booming voice became only a dry whisper. Yet Grandpa’s words, though they became fewer, quieter and more halting, somehow, if anything, grew in impact.

After some initial testing to rule out treatable problems it became clear that there was nothing substantial that we could medically fix.  Grandpa was dying.  In his case, sending him to the hospital would only add misery and isolation to the process. We were able to keep him home as my wife was able to stay with him and many family members and folks from church pitched in to help.  The months carried many labors, many tears, many messes, but also many mercies.  After several days of unresponsiveness, Grandpa would suddenly wake up clear-headed and bless, guide, or express affection for someone in simple words given mass because of the man from whom they came.

There was a certain soul-satisfaction in meeting his basic needs.  And though there were sharp words on rare occasions, Grandpa was mostly humble and appreciative.  I am well aware that for many caring for aging or dying parents it is not that way.  These were great mercies to us.

In Grandpa’s case we were very thankful to be able to keep him home and let him spend his last weeks surrounded by people he loved and who loved him.  His final passing was gentle.  Though death is almost never pretty, his was at least peaceful.  Over his final few days, Grandpa became almost completely silent except for his increasingly labored breathing.  Then one morning he lay in his bed in our home watched by his oldest daughter and finally there was a breath not followed by any more.  He was wholly silent… but not really. It is not just wishful poetry to say that Grandpa’s voice still projects to us.  His life and words resonate in our mind and heart.  God gave this humble, hard-working dairy farmer much mercy and an unusually powerful gift of projection, and I can still hear him loud and clear. And the temporary labors and messes of the past months are more than outweighed by the memorable mercies.