What is the current management of Bell’s palsy?

From the Guidelines

The current management of Bell's palsy primarily involves early corticosteroid therapy, ideally started within 72 hours of symptom onset, as it has been shown to significantly improve facial nerve function and reduce the risk of long-term complications 1.

Key Recommendations

• Oral steroids should be prescribed within 72 hours of symptom onset for Bell’s palsy patients 16 years and older 1, with a strong recommendation based on high-quality randomized controlled trials.
• Antiviral therapy with valacyclovir or acyclovir may be added, particularly in cases with severe paralysis, though evidence for its benefit is less robust than for steroids 1.
• Eye protection is crucial for patients with incomplete eye closure; artificial tears during the day, lubricating ointment at night, and taping the eye closed or using an eye patch may be necessary to prevent corneal damage 1.
• Physical therapy, including facial exercises and massage, may help maintain muscle tone during recovery, although the evidence for its effectiveness is limited 1.

Rationale

The use of oral steroids within 72 hours of symptom onset has been consistently shown to improve outcomes in Bell's palsy patients, with studies demonstrating significant improvements in facial nerve function and reduced risk of long-term complications 1. The addition of antiviral therapy may be considered in certain cases, although the evidence for its benefit is less clear 1. Eye protection and physical therapy are also important components of management, although the evidence for their effectiveness is limited 1.

Key Studies

• Sullivan et al's double-blind, placebo-controlled, randomized factorial trial involving 551 patients, which reported significant improvement of facial nerve function in patients treated with prednisolone within 72 hours of onset 1.
• Engstrom et al's randomized, double-blind, placebo-controlled, multicenter trial involving 829 patients, which compared the short- and long-term effects of prednisolone and valacyclovir in facial nerve recovery attributed to Bell’s palsy 1.

From the Research

Current Management of Bell's Palsy

The current management of Bell's palsy involves the use of corticosteroids, with or without antiviral agents.

• Corticosteroids, such as prednisolone, have been shown to significantly improve the chances of complete recovery at 3 and 9 months 2, 3, 4.
• The use of high-dose corticosteroids (≥80 mg) has been found to be more effective than standard-dose corticosteroids (40-60 mg) in reducing the risk of nonrecovery at 6 months follow-up 5.
• Antiviral agents, such as acyclovir or valaciclovir, have not been found to provide a significant benefit in the treatment of Bell's palsy when used alone or in combination with corticosteroids 2, 3, 4.

Treatment Recommendations

• Early treatment with prednisolone is recommended for patients with Bell's palsy, with a dose of 60 mg per day for 5 days, followed by a tapering dose over the next 5 days 2, 4.
• High-dose corticosteroids (≥80 mg) may be considered for patients with severe Bell's palsy or those who are at high risk of nonrecovery 5.
• Antiviral agents are not recommended for the treatment of Bell's palsy, unless there is evidence of a viral infection, such as herpes simplex or varicella-zoster 3, 4.

Adverse Events

• The use of corticosteroids and antiviral agents has been found to be generally safe, with few adverse events reported 2, 3, 4.
• High-dose corticosteroids have been found to be associated with a higher risk of adverse events, such as transient elevated liver enzymes and fecal occult blood 5.