From the Guidelines
The patient's diagnosis appears to be Bell's palsy, and the current treatment approach, including prednisone 80 mg for 5 days and valacyclovir 1000 mg TID for 2 days, is appropriate, as early corticosteroid treatment within 72 hours of symptom onset significantly improves outcomes by reducing inflammation of the facial nerve, as shown in studies such as Sullivan et al 1. The patient's symptoms, including unilateral facial weakness, inability to close the eye, and sensory changes, are consistent with Bell's palsy.
- The use of Naproxen 500 mg BID for neck pain is a reasonable choice.
- Ordering an MRI to rule out stroke is prudent given the patient's age and symptoms.
- A neurologist consultation after obtaining MRI results will help confirm the diagnosis and guide further management.
- Physical therapy with facial exercises is beneficial for recovery in Bell's palsy and should be initiated promptly, as it can help improve facial function and reduce the risk of long-term functional impairment.
- Eye protection is crucial since the patient cannot fully close his right eye; artificial tears during the day and eye ointment at night with eye patching will prevent corneal damage, as recommended by Baugh et al 1.
- Bell's palsy is often caused by reactivation of herpes simplex virus affecting the facial nerve, which explains the use of antiviral medication.
- Most patients with Bell's palsy recover completely within 3-6 months, but early corticosteroid treatment significantly improves outcomes, with studies such as Engstrom et al 1 showing that 83% of patients treated with prednisolone within 72 hours of onset had recovered facial nerve function 3 months after treatment. The patient should be educated about strategies for eye closure and moisturization, and referred to an ophthalmologist or eye specialist for evaluation and treatment if necessary, as well as to a facial plastic and reconstructive surgeon if the patient has not shown meaningful functional recovery, to discuss reconstructive procedures such as eyelid weights, brow lifts, and static and dynamic facial slings. Additionally, the patient may benefit from support or counseling to deal with the emotional and physical consequences of persistent facial paresis/paralysis, and referral to a specialist for management of depression or chronic pain if necessary.
From the Research
Patient Symptoms and Treatment
- The patient's symptoms, including left-side neck pain, numbness on the right side of the face, and inability to close the right eye completely, are consistent with Bell's palsy 2, 3, 4, 5, 6.
- The treatment with prednisone 80 mg for 5 days and valacyclovir 1000 mg TID for 2 days is in line with the recommended treatment for Bell's palsy, which includes a course of corticosteroids and antiviral medication 2, 3, 4.
- The prescription of Naproxen 500 mg BID for neck pain is a common treatment for pain management 2, 3.
- The request for an MRI to rule out stroke is a necessary step to exclude other potential causes of the patient's symptoms 4, 5.
- The referral to a neurologist consult after the MRI results is a reasonable step to ensure proper evaluation and management of the patient's condition 3, 4.
- The prescription of physical therapy with facial exercises may help with recovery, although the evidence for this is limited 3, 6.
Diagnosis and Management
- Bell's palsy is a diagnosis of exclusion, and a thorough history and physical examination are necessary to establish the correct diagnosis 3, 4, 6.
- The diagnosis of Bell's palsy is characterized by an acute onset of unilateral, lower motor neuron weakness of the facial nerve in the absence of an identifiable cause 3, 4.
- Corticosteroids are the mainstay of treatment for Bell's palsy, and should be initiated within 72 hours of symptom onset 3, 4.
- Antiviral therapy in combination with corticosteroid therapy may confer a small benefit, but the evidence for this is limited 2, 3, 4.