What are the treatment guidelines for Bell's palsy (Idiopathic Facial Paralysis)?

From the Guidelines

Treatment for Bell's palsy should always include oral steroids within 72 hours of symptom onset for patients 16 years and older, as this has been shown to significantly improve facial nerve function and reduce the risk of long-term damage. The standard regimen typically involves prednisone 60-80 mg daily for 5-7 days, followed by a taper over the next 5-7 days 1. This recommendation is based on high-quality randomized controlled trials, such as the study by Sullivan et al, which reported significant improvement of facial nerve function in patients treated with prednisolone within 72 hours of onset 1.

Key Considerations

• Antiviral medications like valacyclovir may be added, especially in cases with severe paralysis or involvement of other cranial nerves, though evidence for their benefit is less robust than for steroids 1.
• Eye protection is crucial for patients who cannot fully close the affected eye; artificial tears during the day and lubricating ointment with eye taping at night help prevent corneal damage 1.
• Physical therapy with facial exercises and massage may aid recovery, though should begin after the acute inflammation subsides 1.
• Most patients should expect significant improvement within 3-6 months, with about 70% achieving complete recovery 1.

Important Recommendations

• Clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis 1.
• Clinicians should not obtain routine laboratory testing in patients with new-onset Bell’s palsy, unless there are specific indications 1.
• Clinicians should implement eye protection for Bell’s palsy patients with impaired eye closure 1.
• Patients should seek immediate medical attention if symptoms worsen or fail to improve after treatment, as this may indicate an alternative diagnosis requiring different management 1.

From the Research

Treatment Guidelines for Bell's Palsy

• The overall prognosis for Bell's palsy is good, with more than two-thirds of patients experiencing complete spontaneous recovery 2.
• For children and pregnant women, the rate of complete recovery is up to 90% 2.
• Bell's palsy is idiopathic, and laboratory testing and imaging are not required for diagnosis 2.
• An oral corticosteroid regimen (prednisone, 50 to 60 mg per day for five days followed by a five-day taper) is the first-line treatment for Bell's palsy 2.

Combination Therapy with Antivirals

• Combination therapy with an oral corticosteroid and antiviral may reduce rates of synkinesis (misdirected regrowth of facial nerve fibers) 2.
• Recommended antivirals include valacyclovir (1 g three times per day for seven days) or acyclovir (400 mg five times per day for 10 days) 2.
• Treatment with antivirals alone is ineffective and not recommended 2, 3, 4.
• The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone 4.
• However, the combination of antivirals and corticosteroids probably reduces the late sequelae of Bell's palsy compared with corticosteroids alone 4.

High-Dose Corticosteroids

• High-dose corticosteroids (≥80 mg) may be more effective than standard-dose corticosteroids (40-60 mg) in the treatment of Bell's palsy 5.
• A systematic review and meta-analysis found a significant decrease in nonrecovery with high-dose, compared with standard-dose, corticosteroids at 6 months follow-up 5.

Timing of Treatment Initiation

• Initiating treatment within 72 hours of symptom onset may be associated with higher recovery rates 6.
• However, one study found that initiating treatment beyond 72 hours was associated with a higher recovery rate than starting treatment within 72 hours 6.
• The optimal timing of treatment initiation may depend on individual patient factors, such as age and disease severity 6.

Individualized Treatment Approaches

• Individualized treatment approaches may be important in Bell's palsy management, taking into account factors such as age, disease severity, and patient behavior patterns 6.
• Steroid monotherapy remains effective, although combined treatment may have potential advantages, especially in patients with more severe disease 6.