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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