Bell's Palsy - Diagnosis and Management Summary - GrepMed Handbook
Acute Idiopathic Unilateral Facial Nerve (CN7) Palsy
Presentation:
• Unilateral upper AND lower facial weakness ± hyperacusis, ↓lacrimation, ↓taste, ↓salivation.
• Typical progression: over 1-3d → max severity within 3w, some recovery within 4m
• Atypical Features 🚩:
- Atypical Clinical: Isolated lower, bilateral, non-CN7 neuropathies (ataxia, hearing loss, spasm, ophthalmoplegia), systemic signs (rash, swelling, adenopathy)
- Atypical Temporal: Rapid onset to max severity, prolonged onset (weeks-months), progression >3w, No improvement <4m
• Etiology: Idiopathic, HSV most common. Other: viral, Lyme, facial nerve ischemia
• DDx: HZV (Ramsay-Hunt), HIV, Lyme, GBS, tumor, parotid/middle ear/skull base pathology, sarcoidosis, Sjogrens
Diagnosis and Workup:
• No additional workup needed if typical presentation
• Lyme Serology (if endemic area) ± HIV screening
• Imaging (if atypical symptoms): MRI+gad (stroke, CN7, parotid), CT (middle ear/temporal bone pathology)
• LP (if suspect GBS, sarcoid or other CNS inflammatory cause)
• EMG/NCS (rare): assist prognosis with delayed recovery
Management:
• Glucocorticoids: prednisone 60-80mg/d x 1w OR prednisone 60mg x 5d + 10mg taper x 5d
• Antiviral (unproven benefit, rec for severe Sx): Valacyclovir 1g tid x 1w or Acyclovir 400 mg 5x/d x 10d
• Eyecare (prevent corneal injury):
- Awake: Artificial tears gtt qid+prn
- Sleep: Artificial tears oint + TAPE eye shut (patch alone may be insufficient!)
• Monitoring: New/worsening S/Sx after 3w, no improvement within 4m
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