How should acute peripheral right facial palsy be managed in a 40‑year‑old diabetic woman, and what oral corticosteroid dose should be used?

Management of Acute Peripheral Facial Palsy in a 40-Year-Old Diabetic Woman

Start oral prednisolone 50 mg once daily for 10 days (or prednisone 60 mg daily for 5 days followed by a 5-day taper) within 72 hours of symptom onset, combined with aggressive eye protection measures. 1

Immediate Assessment and Diagnosis

Before initiating treatment, perform a focused examination to exclude alternative causes of facial weakness: 2, 1

• Confirm peripheral pattern: Weakness must involve the forehead (distinguishes from stroke, which spares forehead) 1
• Rule out trauma: Temporal bone fracture or surgical injury 1
• Exclude infection: Check for vesicles suggesting herpes zoster, otoscopy for otitis media 3
• Assess for tumor: Look for recurrent paralysis, isolated branch weakness, or other cranial nerve involvement 1
• Verify acute onset: Symptoms developing over less than 72 hours 1

Do NOT order routine laboratory tests or imaging for typical Bell's palsy presentations. 2, 1 These are unnecessary and delay treatment.

Corticosteroid Treatment Protocol

Dosing Regimen (Choose One)

Option 1 (Preferred): Prednisolone 50 mg orally once daily for 10 days 1, 3

Option 2: Prednisone 60 mg orally once daily for 5 days, then taper by 10 mg daily over 5 days 1, 4

Critical Timing

• Must initiate within 72 hours of symptom onset 2, 1
• Treatment beyond 72 hours lacks evidence of benefit 1, 5
• Early treatment reduces inflammation before permanent nerve damage occurs 5

Evidence Supporting Steroids

• 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1
• Number needed to treat = 10 3

Special Consideration for Diabetes

Diabetic patients have worse prognosis than non-diabetics: 6

• Recovery rate at 6 months: 52.6% in diabetics versus 82.5% in non-diabetics 6
• Facial movement scores remain lower at 3 and 6 months post-onset 6

Despite hyperglycemia risk, corticosteroids remain first-line treatment. 7, 4 Monitor blood glucose closely during treatment and adjust diabetic medications as needed. The benefit of preventing permanent facial weakness outweighs the temporary hyperglycemia risk. 3

Common Steroid Pitfalls to Avoid

• Never use methylprednisolone dose packs: They provide only 84-105 mg total versus 540 mg needed, representing gross underdosing 1, 5
• Do not divide the daily dose: Give as single daily dose for optimal effect 5
• Do not exceed 60 mg daily maximum dose 5

Antiviral Therapy Decision

Antiviral monotherapy alone is NEVER appropriate. 2, 1, 7

Optional combination therapy: May add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to the steroid regimen 1, 4

• Combination therapy shows modest additional benefit (96.5% recovery versus 89.7% with steroids alone) 1
• Consider in severe cases with complete paralysis or intense pain 3
• Risks are minimal, but benefit is small 1

Eye Protection Protocol (Mandatory)

Implement immediately for any patient with impaired eye closure: 1

Daytime Protection

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

Nighttime Protection

• Ophthalmic ointment (dexpanthenol or similar) at bedtime 1, 3
• Eye taping or patching with proper technique instruction 1
• Consider moisture chambers (polyethylene covers) for severe cases 1

Urgent Ophthalmology Referral Indications

• Complete inability to close eye 1
• Eye pain, vision changes, or redness 1
• Signs of corneal exposure or damage 1

Follow-Up Schedule

Week 1-2

• Reassess facial nerve function using House-Brackmann grading 8
• Verify adequate eye protection compliance 8
• Monitor blood glucose in diabetic patients 9

Month 3 (Mandatory Reassessment)

Refer to facial nerve specialist if: 2, 1

• Incomplete facial recovery at 3 months 1
• New or worsening neurologic findings at any point 1
• Ocular symptoms develop at any point 1

Expected Recovery Timeline

• Most patients begin recovery within 2-3 weeks 1, 8
• Complete recovery typically occurs within 3-4 months 1
• 70% with complete paralysis recover fully by 6 months 1
• Diabetics recover more slowly and less completely 6

What NOT to Do

• Do not prescribe antiviral therapy alone 2, 1, 7
• Do not order routine labs or imaging for typical presentations 2, 1
• Do not perform electrodiagnostic testing for incomplete paralysis 2
• Do not restart or extend corticosteroids beyond initial 10-day course 8
• Do not recommend acupuncture or physical therapy as primary treatment (no proven benefit) 2, 1

Red Flags Requiring Imaging and Specialist Referral

Order MRI with and without contrast if: 1

• Recurrent paralysis on same side 1
• Bilateral facial weakness 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1