What is the appropriate management for a 49-year-old man with right‑sided Bell palsy of 3‑day onset?

Management of Right-Sided Bell's Palsy at 3 Days Onset

Start oral corticosteroids immediately—you are still within the critical 72-hour treatment window where steroids significantly improve facial nerve recovery. 1

Immediate Corticosteroid Therapy (Within 72 Hours)

Prescribe one of these regimens today:

• Prednisolone 50 mg once daily for 10 days (no taper needed), OR 1
• Prednisone 60 mg once daily for 5 days, then taper by 10 mg each day for 5 additional days (total 10 days) 1

Evidence supporting this approach:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo (NNT = 6) 1
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo (NNT = 8) 1
• Treatment initiated after 72 hours has no proven benefit and should be avoided 2

Optional Antiviral Combination Therapy

You may add (but do not substitute) an antiviral to the steroid regimen:

• Valacyclovir 1000 mg three times daily for 7 days, OR 1
• Acyclovir 400 mg five times daily for 10 days 1

Important caveats:

• Antivirals alone are completely ineffective and must never be prescribed as monotherapy 1, 3
• The added benefit of combination therapy is modest: 96.5% recovery versus 89.7% with steroids alone (absolute benefit +6.8%) 1
• The large BELLS trial found no statistically significant advantage of adding acyclovir (71.2% vs 75.7%, P=0.50) 1
• This remains an "option" rather than a formal recommendation due to the small incremental gain 1

Mandatory Eye Protection (Start Today)

For any degree of impaired eye closure, implement all of the following:

• Lubricating eye drops every 1–2 hours while awake 1
• Ophthalmic ointment at bedtime for sustained overnight moisture 1
• Eye taping or patching at night with proper technique instruction to avoid corneal abrasion 1
• Sunglasses outdoors to shield against wind and debris 1
• Consider moisture chambers (polyethylene covers) for severe lagophthalmos 1

Urgent ophthalmology referral if:

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1

What NOT to Do

Avoid these common errors:

• Do NOT order routine laboratory tests—they delay treatment without improving outcomes 1, 3
• Do NOT obtain imaging (CT/MRI)—unnecessary for typical Bell's palsy and wastes the treatment window 1, 3
• Do NOT perform electrodiagnostic testing unless complete facial paralysis is present 1
• Do NOT prescribe antivirals alone—they are ineffective as monotherapy 1, 3
• Do NOT use a standard methylprednisolone dose pack—it provides only 105 mg prednisone-equivalent versus the required 540 mg total exposure 1

Confirm the Diagnosis

Before initiating treatment, verify these features:

• Acute onset within 72 hours with unilateral facial weakness involving the forehead 1, 4
• Forehead involvement present (inability to wrinkle brow)—forehead sparing suggests central stroke, not Bell's palsy 1
• No other cranial nerve deficits—involvement of any other cranial nerve excludes Bell's palsy and mandates immediate imaging 1
• No cortical signs (e.g., language disturbance, limb weakness)—these indicate stroke 1

Follow-Up Schedule

Arrange reassessment at these intervals:

• 1–2 weeks: Monitor recovery trajectory, reinforce eye protection, identify early complications 1
• 3 months (mandatory): Refer to facial nerve specialist if recovery is incomplete 1, 3

Immediate referral triggers at any time:

• New or worsening neurologic findings 1, 3
• Development of ocular symptoms (pain, vision changes, redness) 1, 3
• Progressive weakness beyond 3 weeks 1

Red Flags Requiring Imaging

Order MRI with and without contrast if any of these are present:

• Recurrent paralysis on the same side 1
• Isolated branch paralysis (e.g., only lower face) 1
• Bilateral facial weakness 1
• Other cranial nerve involvement 1
• Progressive weakness beyond 3 weeks 1
• Forehead sparing (suggests stroke) 1

Prognosis Counseling

Provide realistic expectations:

• Most patients begin showing recovery within 2–3 weeks 1
• Complete recovery typically occurs within 3–4 months 1
• Patients with incomplete paralysis have up to 94% complete recovery rates 1
• Patients with complete paralysis have approximately 70% complete recovery rates within 6 months 1
• 30% may experience permanent facial weakness with muscle contractures 1

Special Considerations for This Patient

At 49 years old with no mentioned comorbidities:

• Standard adult dosing applies (no weight-based adjustment needed unless significantly underweight or overweight) 1
• Screen for diabetes and hypertension, as these increase Bell's palsy risk 1
• If diabetic, monitor glucose closely during steroid therapy—expect daytime hyperglycemia with morning dosing 1