What is the best treatment approach for a 50-year-old male with a 3-week history of left facial droop, diagnosed with Bell's palsy, and a negative head computed tomography (CT) scan?

Treatment of Bell's Palsy at 3 Weeks Post-Onset

Critical Assessment: You Are Outside the Treatment Window

Unfortunately, at 3 weeks post-onset, this patient has missed the critical 72-hour window for corticosteroid therapy, which is the only proven effective treatment for Bell's palsy. 1

The evidence is clear that corticosteroids must be initiated within 72 hours of symptom onset to significantly improve facial nerve recovery, and there is no evidence supporting benefit after this window. 1 At this point, your management shifts entirely to:

• Aggressive eye protection
• Monitoring for recovery
• Identifying red flags requiring urgent reassessment

Immediate Management Priorities

1. Eye Protection (Most Critical Current Intervention)

Implement comprehensive eye protection immediately to prevent permanent corneal damage. 1

Daytime regimen:

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Sunglasses outdoors for protection against wind and foreign particles 1

Nighttime regimen:

• Ophthalmic ointment at bedtime for sustained moisture retention 1
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
• Consider moisture chambers using polyethylene covers for severe cases 1

Urgent ophthalmology referral if:

• Eye pain, vision changes, redness, discharge, or foreign body sensation develops 1
• Severe impairment with complete inability to close the eye 1

2. Urgent Reassessment for Red Flags

Progressive weakness beyond 3 weeks is a red flag that requires immediate reassessment, as it may indicate a condition other than Bell's palsy. 1

This patient's symptoms have persisted for 3 weeks without mention of improvement. You must perform a focused neurological examination looking for:

• New cranial nerve involvement (suggests alternative diagnosis) 1
• Bilateral facial weakness (rare in Bell's palsy; suggests sarcoidosis, Lyme disease, or neoplasm) 1
• Isolated branch paralysis (atypical for Bell's palsy) 1
• Signs of head and neck malignancy 1

Order MRI with and without contrast if: 1

• Progressive weakness continues
• No signs of recovery by 3 weeks
• Any atypical features are present
• Recurrent paralysis on the same side

Follow-Up Algorithm

At 3 Months Post-Onset (Mandatory Reassessment Point)

All patients with incomplete facial recovery at 3 months must be reassessed or referred to a facial nerve specialist. 1

This is a critical decision point because:

• 70% of patients with complete paralysis recover fully within 6 months 1
• 94% with incomplete paralysis recover 1
• 30% may experience permanent facial weakness requiring reconstructive options 1

Refer to facial nerve specialist for: 1

• Evaluation of reconstructive procedures (static or dynamic facial slings, nerve transfers)
• Consideration of eyelid weight implantation or tarsorrhaphy for persistent lagophthalmos
• Psychological support for quality of life issues

Refer to ophthalmology for: 1

• Persistent incomplete eye closure
• Any signs of corneal exposure or damage

Prognosis Discussion

Most patients begin showing signs of recovery within 2-3 weeks of symptom onset, with complete recovery typically occurring within 3-4 months. 1

Since this patient is at 3 weeks:

• If incomplete paralysis at presentation: up to 94% recovery rate 1
• If complete paralysis: approximately 70% complete recovery within 6 months 1
• Recovery should begin soon if this is true Bell's palsy

Common Pitfalls to Avoid

Do not prescribe corticosteroids at 3 weeks post-onset - there is no evidence of benefit beyond 72 hours, and you risk unnecessary side effects. 1

Do not prescribe antiviral monotherapy - it is ineffective and should never be used alone. 1

Do not delay imaging if atypical features are present - progressive weakness beyond 3 weeks warrants MRI to exclude tumor, stroke, or other pathology. 1

Do not underestimate the importance of eye protection - inadequate monitoring can lead to permanent corneal damage, particularly with severe lagophthalmos. 1

Do not fail to refer at 3 months if recovery is incomplete - this delays access to reconstructive options and psychological support. 1

Why Corticosteroids Are Not Indicated Now

The evidence for corticosteroids shows 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo - but only when initiated within 72 hours. 1 The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against initiating corticosteroids beyond 72 hours of symptom onset. 1