What is the diagnostic workup and treatment for a 79-year-old woman with headache and unilateral facial weakness (facial dropping) without limb weakness?

Diagnostic Workup and Treatment for Bell's Palsy in a 79-Year-Old Woman

The 79-year-old woman with headache and unilateral facial weakness requires urgent evaluation to rule out stroke and other serious conditions before diagnosing Bell's palsy, followed by prompt treatment with oral corticosteroids within 72 hours of symptom onset if Bell's palsy is confirmed.

Initial Assessment

• A thorough history and physical examination are essential to exclude identifiable causes of facial paresis/paralysis, as Bell's palsy is a diagnosis of exclusion 1
• Key diagnostic criteria for Bell's palsy include:
  • Acute onset (<72 hours) of unilateral facial weakness/paralysis 1
  • Involvement of both upper and lower facial muscles on the affected side 2
  • Absence of other neurologic findings 2
  • No identifiable cause 1

Red Flags Requiring Further Investigation

• The patient's advanced age (79 years) increases stroke risk, which must be ruled out despite the absence of limb weakness 1, 2
• Bilateral facial weakness is rare in Bell's palsy and suggests alternative diagnosis 1
• New or worsening neurologic findings at any point 1
• Slow progression of symptoms (>72 hours) suggests neoplastic or infectious cause 1

Diagnostic Testing

• Routine laboratory testing is NOT recommended for typical presentations of Bell's palsy 1, 2
• Diagnostic imaging is NOT routinely recommended for typical Bell's palsy 1
• However, in this 79-year-old patient with headache, consider:
  • MRI of head, orbit, face and neck with and without contrast (rated 9/9 for appropriateness in facial nerve palsy) to rule out stroke and other causes 1
  • CT head may be appropriate if MRI is contraindicated or unavailable 1

Treatment Recommendations

• Prescribe oral steroids within 72 hours of symptom onset 1, 2
  • Prednisone 50-60 mg daily for 5 days followed by 5-day taper 2
• Consider adding antiviral therapy in combination with steroids 1, 2
  • Valacyclovir 1g three times daily for 7 days OR
  • Acyclovir 400 mg five times daily for 10 days 2
• Do NOT prescribe antiviral therapy alone (strong recommendation against) 1, 2
• Implement eye protection for patients with impaired eye closure 1
  • Artificial tears during the day
  • Lubricating ointment at night
  • Consider eye patch or tape to ensure complete closure

Follow-up and Referral

• Reassess or refer to a facial nerve specialist if: 1
  • New or worsening neurologic findings develop at any point
  • Ocular symptoms develop at any point
  • Incomplete facial recovery after 3 months
• Consider electrodiagnostic testing only if complete facial paralysis is present 1
• No recommendation can be made regarding surgical decompression, acupuncture, or physical therapy 1

Prognosis

• More than two-thirds of patients with typical Bell's palsy have complete spontaneous recovery 2
• Early treatment with corticosteroids improves recovery rates 2, 3
• Most patients recover spontaneously within 3 weeks, even if untreated 3