What are the next steps for an 11-year-old patient with Bell's palsy, currently on prednisone and valacyclovir (antiviral), who is experiencing worsening tingling on the right side of their face 5 days after diagnosis?

Management of Worsening Symptoms in Pediatric Bell's Palsy

This 11-year-old patient with worsening tingling at day 5 requires immediate reassessment to exclude alternative diagnoses, as new or worsening neurologic symptoms at any point mandate specialist evaluation or referral according to current guidelines. 1, 2

Immediate Assessment Required

Urgent clinical reassessment is mandatory because worsening symptoms after treatment initiation may indicate:

• Alternative diagnosis such as tumor, stroke, or other central nervous system pathology that was initially missed 1
• Progression to complete paralysis requiring electrodiagnostic evaluation 1
• Development of complications including corneal exposure or other cranial nerve involvement 1

The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that patients with new or worsening neurologic findings at any point require immediate reassessment or referral to a facial nerve specialist. 3, 1, 2

Specific Red Flags to Evaluate Now

Perform focused examination looking for:

• Bilateral facial weakness (rare in Bell's palsy, suggests alternative diagnosis like Guillain-Barré syndrome) 1
• Isolated branch paralysis (suggests tumor or other structural lesion) 1
• Other cranial nerve involvement (indicates broader neurologic process) 1
• Progression from incomplete to complete paralysis (may warrant electrodiagnostic testing) 1
• Ocular symptoms including eye pain, vision changes, redness, or discharge (requires urgent ophthalmology referral) 1

Current Treatment Continuation

Continue the current regimen of prednisone and valacyclovir as prescribed, assuming the patient is within the initial treatment window. 2 The combination therapy was appropriately initiated, though corticosteroids alone are the cornerstone of treatment. 1, 2

Do not restart or extend corticosteroid therapy beyond the initial 10-day course, as evidence supports only the initial treatment window within 72 hours of symptom onset. 4

Eye Protection Verification

Verify aggressive eye protection is being implemented properly, as this is mandatory for all patients with impaired eye closure:

• Lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Ophthalmic ointment at bedtime 1, 2
• Eye patching or taping at night (with proper technique to avoid corneal abrasion) 1, 2
• Sunglasses for outdoor protection 1, 2
• Moisture chambers for severe cases 1

Symptom Interpretation

Worsening tingling may represent:

• Normal evolution of neuropathic symptoms during the acute phase (not necessarily indicating treatment failure) 5
• Progression of nerve inflammation despite appropriate treatment 5
• Development of hyperacusis or taste disturbance (common associated symptoms) 1

However, any worsening neurologic finding mandates reassessment to exclude misdiagnosis. 3, 1, 2

Imaging Considerations

MRI with and without contrast should be obtained if atypical features are present, including:

• Second paralysis on the same side 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Progression despite appropriate treatment 1

Routine imaging is not recommended for typical Bell's palsy, but worsening symptoms warrant reconsideration of the diagnosis. 3, 1

Pediatric-Specific Considerations

Children have better prognosis than adults, with spontaneous recovery rates up to 90%, but this does not negate the need for reassessment with worsening symptoms. 1, 2

The evidence for corticosteroid benefit in children is less conclusive than in adults, but treatment was appropriately initiated given the clinical presentation. 1, 2

Follow-Up Timeline

Early reassessment within 1-2 weeks (which is now) is valuable for:

• Monitoring recovery progress 1
• Ensuring adequate eye protection 1
• Identifying complications or new neurologic findings 1

Mandatory reassessment at 3 months if facial recovery is incomplete. 1, 2

Common Pitfalls to Avoid

• Assuming all symptom changes are normal progression without excluding alternative diagnoses 1
• Inadequate eye protection monitoring leading to permanent corneal damage 1, 2
• Missing atypical features such as bilateral weakness or other cranial nerve involvement 1
• Delaying specialist referral when red flags are present 1, 2