What are the symptoms and treatment options for Bell's palsy?

Bell's Palsy Symptoms and Treatment

Bell's palsy is characterized by acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours, causing partial or complete inability to move facial muscles on the affected side of the face, including the forehead. 1

Symptoms

Primary Symptoms

• Rapid onset (<72 hours) of unilateral facial weakness or paralysis 1, 2
• Forehead involvement (distinguishing from central facial palsy) 2
• Inability to close the eyelid on affected side 1, 3
• Drooping of the corner of the mouth 4
• Difficulty smiling or whistling 3

Associated Symptoms

• Postauricular pain 4
• Hyperacusis (increased sensitivity to sound) 4
• Dysgeusia (altered taste) 4
• Drooling or dry eyes 4
• Mild fever (in some cases) 4

Diagnostic Approach

• Bell's palsy is a diagnosis of exclusion 1
• No routine laboratory testing is needed for typical presentations 1, 2
• No routine diagnostic imaging for new-onset Bell's palsy 1
• Electrodiagnostic testing is not recommended for incomplete facial paralysis 1

Red Flags (Suggesting Alternative Diagnosis)

• Gradual onset (>72 hours)
• Bilateral facial weakness (rare in Bell's palsy) 1
• Other neurological abnormalities 2
• History suggesting alternative causes (stroke, tumors, Lyme disease) 1

Treatment Algorithm

First-Line Treatment

• Oral corticosteroids should be prescribed within 72 hours of symptom onset 1, 2
  • Prednisone 50-60 mg daily for 5 days followed by 5-day taper 2
  • For patients 16 years and older 1

Antiviral Therapy

• Antiviral therapy alone should NOT be prescribed 1, 2
• Consider combination therapy with corticosteroids and antivirals to reduce risk of synkinesis 2
  • Valacyclovir (1g three times daily for 7 days) OR
  • Acyclovir (400mg five times daily for 10 days) 2

Eye Protection

• Implement eye protection for patients with impaired eye closure 1
  • Artificial tears during the day
  • Lubricating ointment at night
  • Consider eye patch or tape for complete closure at night

Follow-up Care

• Reassess or refer to facial nerve specialist if:
  1. New or worsening neurologic findings develop
  2. Ocular symptoms develop at any point
  3. Incomplete facial recovery after 3 months 1

Prognosis

• More than two-thirds of patients have complete spontaneous recovery 2
• Children and pregnant women have up to 90% complete recovery rate 2
• Early treatment with corticosteroids significantly increases likelihood of improvement 5

Special Populations

• Higher incidence in:
  • Patients with diabetes 6
  • Pregnant women 4
  • People with respiratory infections 4
  • Peak incidence in the 40s 6

Complications

• Short-term: Incomplete eyelid closure with resultant dry eye 6
• Long-term: Permanent facial weakness with muscle contractures 6
• Synkinesis (involuntary co-contraction of facial muscles) 2

Physical therapy may be beneficial for patients with more severe paralysis, though evidence is limited 2.