Bell's Palsy: Immediate Management
Provide prescriptions for corticosteroids, antivirals, artificial tears, and an eye patch and have the patient follow up with her physician. This patient presents with classic Bell's palsy—acute unilateral facial weakness involving the forehead (lower motor neuron pattern), dry eye from incomplete eyelid closure, and no other neurologic deficits 1, 2.
Clinical Reasoning
The clinical presentation is diagnostic for Bell's palsy:
- Acute onset (within hours to 3 days) of unilateral facial weakness 1
- Forehead involvement (inability to wrinkle forehead on affected side), distinguishing this from central causes like stroke 1, 2
- Dry eye from incomplete eyelid closure, a common short-term complication 1
- No other neurologic abnormalities on examination 2
Laboratory testing and imaging are not required for diagnosis when the presentation is typical 2. The suggestion to obtain CT scan and extensive workup is unnecessary and delays appropriate treatment.
Recommended Treatment Protocol
Corticosteroid Therapy (First-Line)
Prednisone 50-60 mg daily for 5 days, followed by a 5-day taper should be initiated immediately 2. Oral corticosteroid therapy is the established first-line treatment and should be started within 3 days of symptom onset to maximize recovery 1, 2.
Antiviral Therapy (Combination Recommended)
Add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 2. While antivirals alone are ineffective, combination therapy with corticosteroids may reduce rates of synkinesis (abnormal facial muscle co-contraction from misdirected nerve fiber regrowth) 2. Given herpes simplex virus type 1 is a possible etiology, combination therapy is reasonable 1, 3.
Eye Protection (Critical)
Prescribe preservative-free artificial tears to be used frequently throughout the day, plus ocular lubricant ointment at bedtime 4. Incomplete eyelid closure creates risk for corneal exposure, desiccation, and potential ulceration 1.
Provide an eye patch or moisture chamber for nighttime use to prevent corneal exposure during sleep when protective blinking is absent 4.
Prognosis and Follow-Up
More than two-thirds of patients achieve complete spontaneous recovery 2. The overall prognosis is good, with symptoms typically peaking in the first week then gradually resolving over 3 weeks to 3 months 1.
Arrange follow-up within 1 week to assess treatment response and eye protection adequacy. If recovery is incomplete after several weeks, consider physical therapy, which may benefit patients with more severe paralysis 2, 5.
Why Other Options Are Incorrect
- Edrophonium testing is for myasthenia gravis, not facial nerve palsy 1
- Prochlorperazine is an antiemetic with no role in Bell's palsy management 1
- Stroke workup with NIH Stroke Scale and neurology consult is inappropriate—the forehead involvement confirms lower motor neuron (peripheral) pathology, not stroke 1, 2