A 52-year-old man from Delhi presents to the emergency department with acute onset facial drooping on the left side, inability to close the left eye, and loss of taste over the anterior two-thirds of the tongue on the left. On examination, the forehead wrinkles are absent on the left, and he cannot whistle. The rest of the neurological examination is normal. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis: Bell's Palsy (Idiopathic Peripheral Facial Nerve Palsy) **Key Point:** The constellation of forehead involvement (absent wrinkles), inability to close the eye, inability to whistle, and loss of taste over the anterior two-thirds of the tongue localizes the lesion to the facial nerve trunk proximal to the chorda tympani — consistent with a **peripheral (LMN) CN VII palsy**. When the clinical picture is classic and no red flags are present, this is Bell's palsy until proven otherwise. **High-Yield:** For a **typical** presentation of Bell's palsy (acute unilateral LMN facial palsy, no other neurological deficits, no parotid mass, no skin lesions, no bilateral involvement), the standard first-line management is **oral corticosteroids + eye care**, with MRI reserved for atypical features or failure to improve. ### Rationale for Correct Answer (Option D) 1. **Classic Bell's palsy presentation**: This patient has a textbook peripheral CN VII palsy — forehead involved (ruling out UMN/central lesion), taste loss (chorda tympani involvement), complete motor paralysis. There are NO red flags: no skin rash (Ramsay Hunt), no bilateral palsy, no parotid mass, no other cranial nerve deficits, no history of malignancy. 2. **Oral corticosteroids are first-line**: According to current guidelines (NICE 2019, Harrison's 21e, and mainstream Indian NEET PG teaching — KD Tripathi), **oral prednisolone** (e.g., 60 mg/day for 5 days, then tapered) initiated within 72 hours is the standard of care. **Intravenous** high-dose corticosteroids are NOT routinely recommended for Bell's palsy and are not standard first-line therapy. 3. **MRI is NOT routinely indicated**: Contrast-enhanced MRI brain is reserved for atypical presentations (progressive palsy >3 weeks, bilateral palsy, recurrence, associated cranial nerve deficits, parotid mass, or failure to recover). Routine MRI in every patient with classic Bell's palsy is not evidence-based and is not standard NEET PG teaching. 4. **Eye care is mandatory**: Lagophthalmos (inability to close the eye) risks corneal exposure keratopathy. Lubricating eye drops, eye patching at night, and protective glasses are essential components of management. 5. **Why Option A is wrong**: IV corticosteroids are not standard first-line for Bell's palsy; urgent MRI is not indicated in a classic, typical presentation without red flags. 6. **Why Option B is wrong**: Serology for Lyme disease and chest X-ray for sarcoidosis are indicated only when there is clinical suspicion (tick exposure, bilateral palsy, systemic features) — not as a routine first step. 7. **Why Option C is wrong**: EMG/NCS within 3 weeks is used for prognostication in severe or complete palsy, not as the immediate next step in management. **Clinical Pearl:** The key distinction in Bell's palsy management is **typical vs. atypical features**. In a typical case (as here), start oral steroids + eye care immediately and reserve MRI for cases that do not follow the expected recovery trajectory or have red flags. [cite: Harrison 21e Ch 379; KD Tripathi Essentials of Medical Pharmacology 8e]