A 34-year-old woman presents with acute LEFT FACIAL DROOP noted on waking, inability to close the left eye, drooling, and loss of facial expression. She reports a 24-hour prodrome of retro-auricular pain, altered taste in the anterior two-thirds of her tongue, and hyperacusis in the left ear. Examination confirms lower motor neuron facial nerve weakness with involvement of the forehead (House-Brackmann grade IV). Otoscopy is NORMAL with NO VESICLES. Pure-tone audiometry is NORMAL with symmetric thresholds, as shown in the diagram marked **A**. Which of the following is the most appropriate INITIAL MANAGEMENT for this patient?

Question

Accepted Answer

C. Oral prednisolone 60–80 mg/day for 7 days started within 72 hours, with eye care and observation. ## Why oral prednisolone 60–80 mg/day for 7 days started within 72 hours is correct

The clinical presentation—acute LMN facial palsy with forehead involvement, retro-auricular pain, hyperacusis (stapedial reflex loss), altered taste (chorda tympani involvement), normal otoscopy (no vesicles), and NORMAL AUDIOGRAM with symmetric thresholds—is diagnostic of BELL PALSY, not Ramsay Hunt syndrome. The normal audiogram marked **A** is the key distinguishing feature: Bell palsy does NOT cause sensorineural hearing loss, whereas Ramsay Hunt characteristically shows SNHL. Bell palsy is the most common cause of acute peripheral facial nerve palsy (20–30 per 100,000 annually) due to HSV-1 reactivation in the geniculate ganglion with nerve entrapment in the labyrinthine segment of the Fallopian canal. According to AAO-HNS 2013 guidelines and Dhingra ENT 7e, ORAL PREDNISOLONE 60–80 mg/day for 7 days initiated within 72 hours significantly improves recovery rates and is the standard of care. Eye care (artificial tears, ointment, taping) is critical to prevent exposure keratitis. Valacyclovir may be added in severe palsy but is NOT first-line monotherapy.

## Why each distractor is wrong

- **Intravenous acyclovir 10 mg/kg TID for 10 days plus prednisolone**: IV acyclovir is reserved for severe immunocompromised patients or when oral therapy cannot be tolerated. Standard Bell palsy management uses ORAL prednisolone ± oral valacyclovir; IV acyclovir is not indicated in an immunocompetent patient presenting within 72 hours.
- **Valacyclovir 1 g TID for 7 days alone without corticosteroids**: Valacyclovir monotherapy without corticosteroids is suboptimal. Evidence supports prednisolone as the primary agent; valacyclovir is adjunctive in severe palsy. Omitting prednisolone delays recovery.
- **MRI brain with contrast immediately, followed by prednisolone only if imaging excludes mass lesion**: MRI is reserved for ATYPICAL features (slow progression >3 weeks, recurrence, other cranial neuropathies, or clinical suspicion of mass). This patient has a CLASSIC presentation of Bell palsy with no red flags. Delaying prednisolone for imaging beyond 72 hours reduces efficacy and is not indicated by AAO-HNS guidelines.

**High-Yield:** Bell palsy = acute LMN facial palsy + normal audiogram (no SNHL); Ramsay Hunt = same presentation + SNHL + vesicles. Prednisolone within 72 hours is standard; imaging only if atypical.

[cite: Dhingra ENT 7e Ch 17; AAO-HNS Bell Palsy Clinical Practice Guideline 2013]

Answer

A. Intravenous acyclovir 10 mg/kg TID for 10 days plus prednisolone

Answer

B. Valacyclovir 1 g TID for 7 days alone without corticosteroids

Answer

D. MRI brain with contrast immediately, followed by prednisolone only if imaging excludes mass lesion

Explanation

Why oral prednisolone 60–80 mg/day for 7 days started within 72 hours is correct

Why each distractor is wrong

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