What is the best course of action for a patient with a mild right-sided facial droop (facial weakness) and no other symptoms?

From the Guidelines

The best course of action for a patient with a mild right-sided facial droop and no other symptoms is to seek immediate emergency medical attention, ideally by calling 911 or going directly to the nearest emergency department. This facial weakness could be a sign of a stroke, which requires rapid assessment and treatment. Time is critical in stroke management, as treatment options like thrombolytic therapy (tPA) are most effective when administered within 4.5 hours of symptom onset. Even if the facial droop is the only symptom, it represents a concerning neurological finding that warrants urgent evaluation. At the hospital, the patient will undergo brain imaging (CT or MRI), blood tests, and neurological assessment to determine the cause. While waiting for emergency services, the patient should not take any food, drink, or medications by mouth as this could be dangerous if swallowing is affected. The facial weakness might also be caused by Bell's palsy, a condition affecting the facial nerve, but this diagnosis can only be made after ruling out more serious conditions like stroke, as suggested by 1. According to 1, MRI is the primary modality for evaluating the intracranial and extracranial portions of the facial nerve, and it is most useful for excluding other causes of facial nerve palsy. However, for patients with new-onset Bell’s palsy, clinicians should not routinely perform diagnostic imaging, as stated in 1. Some key points to consider in the management of facial droop include:

• The importance of early intervention in stroke cases to improve outcomes
• The need to rule out serious conditions like stroke before considering other diagnoses like Bell's palsy
• The role of imaging, particularly MRI, in evaluating the facial nerve and excluding other causes of facial nerve palsy, as discussed in 1 and 1
• The recommendation against routine diagnostic imaging for patients with new-onset Bell’s palsy, as stated in 1. Given the potential severity of the underlying cause, it is crucial to prioritize the patient's safety and seek immediate medical attention. In the emergency department, a thorough evaluation, including history, physical examination, and appropriate imaging studies, will help determine the cause of the facial droop and guide further management, as suggested by 1 and 1.

From the Research

Diagnosis and Treatment of Mild Right-Sided Facial Droop

• The patient's symptoms of mild right-sided facial droop, also known as facial weakness, are characteristic of Bell's palsy, a neuropathy that affects the seventh cranial nerve, the facial nerve 2, 3, 4, 5, 6.
• Bell's palsy is a diagnosis of exclusion, and its treatment ranges from corticosteroids to antivirals, to a combination of both corticosteroids and antivirals, to acupuncture, physical therapy, and chiropractic 2.
• The majority of patients afflicted with Bell's palsy recover facial function, and initial treatment involves oral corticosteroids, possible antiviral drugs, and protection of the eye from desiccation 3.
• A comprehensive examination and complete history are critical for employing a targeted treatment approach, and determining probable causative and risk factors is essential for proper treatment 5.

Outpatient Imaging and Testing

• For patients with typical symptoms of Bell's palsy, no further testing is necessary, and the diagnosis relies upon the presence of typical signs and symptoms 4, 6.
• However, blood chemistry tests, cerebrospinal fluid investigations, nerve conduction studies, and neuroimaging methods (cerebral MRI, x-ray of the skull and mastoid) may be used to diagnose secondary peripheral facial weakness or to rule out other causes of facial weakness 4.
• Outpatient imaging may not be necessary for patients with mild right-sided facial droop and no other symptoms, but it may be considered if the patient's symptoms worsen or if there are atypical features suggesting an alternative cause of peripheral facial palsy 6.

Treatment Options

• Corticosteroids are highly likely to increase the probability of recovery of facial weakness and should be offered to patients with Bell's palsy, especially when used shortly after the onset of symptoms 6.
• The addition of an antiviral to steroids may increase the likelihood of recovery, but only by a very modest effect, and the exact etiology of Bell's palsy is unknown, affecting its treatment 2, 6.
• Other treatment options, such as eye protection, physiotherapy, acupuncture, botulinum toxin, or surgery, may be considered for patients with residual paresis or incomplete recovery 3, 4, 5.