What is the recommended workup and treatment for a patient presenting with Bell's palsy, considering potential complications such as diabetes and hypertension?

Bell's Palsy Workup

Diagnose Bell's palsy clinically through history and physical examination without routine laboratory testing or imaging, then immediately initiate oral corticosteroids within 72 hours and implement aggressive eye protection measures. 1, 2, 3

Clinical Diagnosis

History and Physical Examination

• Confirm acute onset of unilateral facial weakness developing over 24-72 hours involving the forehead (distinguishing it from stroke, which spares the forehead) 1, 2, 3
• Systematically assess all facial movements: raising eyebrows, closing eyes tightly, smiling, and puffing out cheeks 2
• Grade severity using the House-Brackmann scale (Grade 1 = normal function to Grade 6 = total paralysis) 2
• Evaluate for associated symptoms: ipsilateral ear/face pain, hyperacusis (increased sound sensitivity), taste disturbance on anterior two-thirds of tongue, and dry eye/mouth 2
• Exclude alternative diagnoses by ruling out trauma (temporal bone fracture, surgical injury), infection, tumor, stroke, bilateral weakness, isolated branch paralysis, or other cranial nerve involvement 1, 2, 3

Red Flags Requiring Imaging (MRI with and without contrast)

• Recurrent paralysis on the same side 2
• Progressive weakness beyond 3 weeks 2
• Bilateral facial weakness 2
• Isolated branch paralysis 2
• Other cranial nerve involvement 2
• No recovery after 3 months 2

Diagnostic Testing: What NOT to Do

Do not obtain routine laboratory testing or diagnostic imaging for typical Bell's palsy presentations. 1, 2, 3 This increases costs without benefit and delays appropriate treatment.

Electrodiagnostic testing (ENoG/EMG) is only indicated for:

• Complete facial paralysis (not incomplete paralysis) 1, 2
• Testing performed 3-14 days post-onset (before 7 days or after 14-21 days provides unreliable prognostic information) 2
• Greater than 10% nerve response amplitude predicts excellent prognosis; less than 10% carries up to 50% risk of incomplete recovery 2

Treatment Algorithm

Within 72 Hours of Symptom Onset (Critical Window)

1. Initiate oral corticosteroids immediately (strong recommendation): 1, 2, 3, 4

   • Prednisolone 50 mg daily for 10 days OR
   • Prednisone 60 mg daily for 5 days, then 5-day taper (reduce by 10 mg daily)
   • Evidence: 83% recovery at 3 months with prednisolone vs 63.6% with placebo; 94.4% recovery at 9 months vs 81.6% with placebo 2, 4
   • No benefit beyond 72 hours 2, 3

2. Consider combination therapy with antivirals (optional, minimal added benefit): 1, 2, 3

   • Valacyclovir 1 g three times daily for 7 days OR
   • Acyclovir 400 mg five times daily for 10 days
   • Never prescribe antivirals alone—completely ineffective 1, 2, 3, 4
   • Combination therapy shows 96.5% complete recovery vs 89.7% with steroids alone, but benefit is small 2

3. Implement mandatory eye protection for all patients with impaired eye closure: 1, 2, 3

   • Lubricating eye drops every 1-2 hours while awake 2, 3
   • Ophthalmic ointment at bedtime 2, 3
   • Sunglasses outdoors 2, 3
   • Eye taping or patching at night (with careful instruction to avoid corneal abrasion) 2, 3
   • Moisture chambers using polyethylene covers for severe cases 2
   • Urgent ophthalmology referral for severe impairment with complete inability to close eye or signs of corneal exposure 2

Special Populations

Diabetes and Hypertension

• These comorbidities do not contraindicate corticosteroid use for Bell's palsy 1
• Monitor blood glucose closely in diabetic patients during short-term steroid course 1
• Monitor blood pressure in hypertensive patients 1
• The 10-day treatment course is brief enough that benefits outweigh risks 2, 3

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 2, 3
• Eye protection measures are essential and safe in pregnancy 2

Children

• Better prognosis than adults with higher spontaneous recovery rates (up to 90%) 2, 5
• Consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis after shared decision-making with caregivers 2, 3
• Evidence for steroid benefit in children is less conclusive than in adults 2

Follow-Up Schedule

Initial Visit: Within 72 hours of symptom onset 2

• Initiate treatment and provide eye care education

Early Follow-Up: 1-2 weeks after onset 2

• Assess recovery trajectory
• Reinforce eye protection
• Identify early complications

Mandatory Reassessment or Specialist Referral at 3 Months if: 1, 2, 3

• Incomplete facial recovery
• New or worsening neurologic findings at any point
• Development of ocular symptoms at any point

Prognosis

Incomplete Paralysis at Presentation:

• Up to 94% complete recovery 2, 5
• Excellent prognosis with faster recovery 2

Complete Paralysis:

• Approximately 70% complete recovery within 6 months 2, 5
• Most patients begin showing recovery within 2-3 weeks 2
• Complete recovery typically occurs within 3-4 months 2

Poor Prognostic Indicators:

• Complete paralysis with electrodiagnostic testing showing <10% function (up to 50% risk of incomplete recovery) 2
• Approximately 30% may experience permanent facial weakness with muscle contractures 2

Common Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours eliminates treatment effectiveness 2, 3
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 3, 4
• Inadequate eye protection leads to permanent corneal damage 2, 3
• Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2, 3
• Failing to refer at 3 months with incomplete recovery delays access to reconstructive options 2
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 2, 3
• Using standard methylprednisolone dose packs provides only 105 mg prednisone equivalent vs 540 mg over 14 days with proper dosing—significant underdosing 2

Therapies Without Proven Benefit

• Physical therapy: No proven benefit over spontaneous recovery 2, 6
• Acupuncture: No recommendation can be made due to poor-quality trials 1, 2
• Electrical nerve stimulation: No specific recommendation; risk of delaying established treatments 6
• Surgical decompression: Rarely indicated except in specialized circumstances 1, 2