What is the diagnosis and treatment for a 54-year-old male with no significant medical history, presenting with a 24-hour history of right-sided facial droop and inability to wrinkle his forehead, without headache, fever, or trauma, and normal vital signs?

Bell's Palsy: Diagnosis and Management

This patient has Bell's palsy and should be started immediately on oral corticosteroids (prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper) along with aggressive eye protection measures. 1

Diagnosis

This 54-year-old male presents with classic Bell's palsy: acute unilateral facial weakness with onset less than 72 hours, involving the forehead (inability to wrinkle forehead on right side), without identifiable cause. 2, 1

Key diagnostic features confirming Bell's palsy:

• Right-sided facial droop with forehead involvement distinguishes this from stroke (which spares the forehead) 1, 3
• No fever, headache, or trauma excludes infectious, inflammatory, or traumatic etiologies 2, 1
• Normal vital signs and absence of other neurologic symptoms excludes stroke and central causes 1, 3
• Onset within 24 hours (less than 72-hour window) is consistent with Bell's palsy 2, 1

No imaging or laboratory testing is indicated for this typical presentation. 1, 3

Immediate Treatment Protocol

Corticosteroids (Must Start Within 72 Hours)

Prescribe one of these regimens immediately: 1

• Prednisolone 50 mg orally daily for 10 days, OR
• Prednisone 60 mg orally daily for 5 days, then taper over 5 days

Evidence 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. 1 This is the only proven effective treatment for Bell's palsy. 1

Antiviral Therapy (Optional)

May offer valacyclovir or acyclovir in combination with steroids (not alone) within 72 hours, though benefit is minimal. 1 Combination therapy shows 96.5% complete recovery versus 89.7% with steroids alone—a small but potentially meaningful difference with minimal risk. 1

Never prescribe antivirals as monotherapy—they are ineffective alone. 1

Eye Protection (Critical to Prevent Permanent Corneal Damage)

Implement all of the following measures immediately: 1

Daytime Protection

• Lubricating eye drops every 1-2 hours while awake 1
• Sunglasses outdoors to protect against wind and foreign particles 1

Nighttime Protection

• 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

Refer urgently to ophthalmology if:

• Complete inability to close the eye 1
• Any signs of corneal exposure or damage (pain, redness, vision changes) 1

Follow-Up Schedule

Mandatory Reassessment Points

At 3 months: Reassess or refer to facial nerve specialist if facial recovery is incomplete. 1

At any time, refer immediately if: 1

• New or worsening neurologic findings develop
• Ocular symptoms develop (pain, vision changes, redness)
• Progressive weakness beyond 3 weeks (suggests alternative diagnosis) 3

Early Follow-Up (1-2 Weeks)

Schedule within 1-2 weeks to monitor recovery progress, reinforce eye protection, and identify early complications. 1

Prognosis

Reassure the patient: 1

• Most patients begin showing recovery within 2-3 weeks
• Complete recovery typically occurs within 3-4 months
• Approximately 70% with complete paralysis recover fully within 6 months
• Patients with incomplete paralysis (like this patient who can still partially move his face) have up to 94% recovery rates

However, warn that: 1

• 30% may experience some permanent facial weakness
• Long-term sequelae may include facial contractures, synkinesis, or persistent eye problems

Critical Pitfalls to Avoid

Do not delay steroid treatment beyond 72 hours—effectiveness decreases significantly after this window. 1

Do not prescribe antivirals alone—they are completely ineffective as monotherapy and delay appropriate corticosteroid treatment. 1

Do not underestimate eye protection—inadequate corneal protection can lead to permanent corneal damage, particularly in patients with severe lagophthalmos. 1

Do not order routine imaging or labs for typical presentations—this wastes resources and delays treatment. 1, 3

Do not miss red flags requiring imaging: 1, 3

• Bilateral facial weakness (suggests Lyme disease, sarcoidosis, or Guillain-Barré syndrome)
• Other cranial nerve involvement
• Progressive weakness beyond 3 weeks
• Recurrent paralysis on the same side