In a 26-year-old Hispanic female with acute right-sided facial droop and inability to fully close the right eye, what history questions should be asked, what pertinent physical exam findings are needed, what are the differential diagnoses, and what is the appropriate treatment plan?

Acute Right-Sided Facial Droop in a 26-Year-Old Female: Clinical Approach

Step 1: History of Present Illness – Critical Questions to Ask

Onset and Timing:

• Exactly when did the facial weakness begin, and how rapidly did it progress (Bell's palsy develops over 24-72 hours)? 1
• Has the weakness worsened beyond 3 weeks (progressive weakness suggests tumor or infection, not Bell's palsy)? 1

Associated Symptoms:

• Any pain around the right ear or face (common in Bell's palsy)? 1, 2
• Difficulty closing the right eye completely, or any eye pain, redness, or vision changes (indicates risk of corneal exposure)? 1
• Any taste disturbance on the anterior tongue or increased sensitivity to sound (hyperacusis suggests proximal facial nerve involvement)? 2, 1
• Dry eye or dry mouth symptoms? 2

Red-Flag Neurologic Symptoms (these exclude Bell's palsy):

• Any dizziness, difficulty swallowing, double vision, limb weakness, or numbness elsewhere (suggests brainstem pathology or stroke)? 3, 1
• Any other cranial nerve symptoms (involvement of any nerve besides CN VII excludes Bell's palsy)? 1
• Any headache, fever, or neck stiffness? 3

Risk Factors and Past History:

• Diabetes, hypertension, obesity, or pregnancy (all increase Bell's palsy risk)? 1
• Recent viral illness or upper respiratory infection? 4
• History of Lyme disease exposure or tick bites (especially in endemic areas)? 1
• Any prior episodes of facial weakness, especially on the same side (recurrence suggests tumor)? 1
• Recent head trauma, ear surgery, or parotid surgery? 2, 1

Step 2: Physical Examination – Pertinent Findings to Document

Facial Nerve Function Assessment:

• Forehead involvement is mandatory for Bell's palsy diagnosis: Can she wrinkle her forehead or raise her right eyebrow (forehead sparing indicates central stroke, not Bell's palsy)? 1, 2
• Ability to close the right eye tightly (measure lagophthalmos in millimeters)? 1
• Smile symmetry and ability to puff out cheeks? 1
• Grade severity using House-Brackmann scale (Grade 1 = normal to Grade 6 = complete paralysis)? 2, 1

Eye Protection Assessment:

• Completeness of eye closure and presence of Bell's phenomenon (upward eye rotation with attempted closure)? 1
• Corneal examination for exposure keratitis, dryness, or abrasions? 1
• Tear production and blink reflex? 1

Complete Cranial Nerve Examination (to exclude other pathology):

• Test all cranial nerves systematically; any additional cranial nerve deficit excludes Bell's palsy and mandates immediate imaging 1, 3
• Pupillary responses (anisocoria or abnormal light reflex suggests third nerve involvement)? 5
• Extraocular movements (diplopia or ophthalmoplegia suggests brainstem lesion)? 5
• Facial sensation in all three trigeminal divisions? 1
• Hearing assessment (diminished hearing may indicate stapedius involvement)? 2, 6

Neurologic Examination:

• Motor strength in all extremities (hemiparesis indicates stroke)? 3
• Coordination and gait (ataxia suggests cerebellar or brainstem pathology)? 3
• Mental status and speech (aphasia or dysarthria suggests central lesion)? 1

Otoscopic Examination:

• Vesicles in the ear canal (suggests Ramsay Hunt syndrome from varicella-zoster virus)? 7

Step 3: Differential Diagnoses

Most Likely: Bell's Palsy (Acute Idiopathic Facial Nerve Palsy)

• Acute unilateral facial weakness with forehead involvement, onset <72 hours, no other neurologic deficits 1, 2
• Accounts for 38% of facial palsy cases in tertiary centers 8
• 70-80% recover spontaneously, but treatment improves outcomes 4, 1

Alternative Diagnoses to Exclude:

Central Causes (forehead sparing):

• Stroke/TIA: Forehead sparing, possible aphasia, hemiparesis, or other cortical signs 1, 2
• Brainstem lesion: Additional cranial nerve involvement, ataxia, or crossed findings 3

Peripheral Causes (forehead involved):

• Ramsay Hunt syndrome (VZV): Vesicles in ear canal, severe pain, worse prognosis 7, 1
• Lyme disease: Endemic area exposure, may have erythema migrans 1, 4
• Tumor (acoustic neuroma, parotid tumor, cholesteatoma): Gradual onset, recurrent episodes, or other cranial nerve involvement 1, 8
• Trauma: Recent head injury or temporal bone fracture 2, 1
• Otitis media or mastoiditis: Ear pain, fever, otoscopic findings 1

Systemic Causes:

• Sarcoidosis, Guillain-Barré syndrome (bilateral facial weakness), HIV, diabetes-related neuropathy 3, 8

Step 4: Treatment Plan

Immediate Management (Within 72 Hours of Symptom Onset)

Primary Treatment – Oral Corticosteroids (STRONG RECOMMENDATION):

• Prescribe prednisolone 50 mg once daily for 10 days OR prednisone 60 mg once daily for 5 days followed by 5-day taper (10 mg decrements) 1, 7
• Must initiate within 72 hours of symptom onset; no benefit after this window 1
• Evidence: 83% complete recovery at 3 months with prednisolone vs. 64% with placebo (NNT = 6); 94% recovery at 9 months vs. 82% with placebo 1

Optional Antiviral Therapy (WEAK RECOMMENDATION):

• May add valacyclovir 1000 mg three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours 1
• Small incremental benefit: 96.5% recovery with combination vs. 89.7% with steroids alone 1
• Never prescribe antivirals as monotherapy; they are ineffective alone 1

Mandatory Eye Protection (STRONG RECOMMENDATION for all patients with incomplete eye closure):

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Ophthalmic ointment (dexpanthenol or similar) at bedtime 1, 7
• Eye taping or patching at night with proper technique instruction to avoid corneal abrasion 1
• Sunglasses outdoors for wind and debris protection 1
• Moisture chambers (polyethylene covers) for severe lagophthalmos 1
• Urgent ophthalmology referral if complete inability to close eye or signs of corneal exposure 1

Diagnostic Testing – What NOT to Order

Do NOT obtain routine laboratory tests or imaging for typical Bell's palsy presentation:

• No routine labs (delays treatment beyond 72-hour window without improving outcomes) 1
• No routine CT or MRI for classic presentation 1
• No electrodiagnostic testing for incomplete facial paralysis 1

Reserve MRI (with and without contrast) ONLY for atypical features:

• Recurrent paralysis on same side, isolated branch paralysis, other cranial nerve involvement, bilateral facial weakness, forehead sparing, progressive weakness beyond 3 weeks, or no recovery after 3 months 1

Optional electrodiagnostic testing:

• May offer to patients with complete facial paralysis only, performed 3-14 days post-onset for prognostic information 1

Follow-Up and Referral Triggers

Mandatory Reassessment or Specialist Referral:

• Incomplete facial recovery at 3 months after symptom onset 1
• New or worsening neurologic findings at any point 1
• Development of ocular symptoms at any point 1

Early Follow-Up (1-2 Weeks):

• Assess recovery trajectory, reinforce eye protection, identify early complications 1

Long-Term Management for Incomplete Recovery:

• Refer to facial nerve specialist or facial plastic surgeon for reconstructive options (eyelid weights, tarsorrhaphy, nerve transfers, facial slings) 1
• Ophthalmology referral for persistent lagophthalmos 1
• Screen for depression and provide psychological support (30% have permanent weakness with significant psychosocial impact) 1

Common Pitfalls to Avoid

• Missing the 72-hour treatment window (efficacy of steroids diminishes significantly after this timeframe) 1
• Diagnosing Bell's palsy when forehead is spared (indicates central stroke requiring immediate imaging) 1
• Prescribing antiviral monotherapy (ineffective and delays appropriate steroid treatment) 1
• Inadequate eye protection (can lead to permanent corneal damage and vision loss) 1
• Failing to recognize red-flag features (other cranial nerve involvement, bilateral weakness, progressive course beyond 3 weeks) that mandate imaging and specialist referral 1
• Ordering unnecessary labs or imaging for typical presentations (increases cost and delays treatment) 1