What is the initial treatment approach for a patient presenting with Bell's palsy in the emergency setting?

Emergency Evaluation and Treatment of Bell's Palsy

For patients presenting with Bell's palsy in the emergency setting, oral corticosteroids should be prescribed within 72 hours of symptom onset as the primary treatment. 1

Diagnosis and Initial Assessment

Bell's palsy is defined as an acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without an identifiable cause. The following assessment should be performed:

• Key diagnostic features:

  • Rapid onset (<72 hours) of unilateral facial weakness/paralysis
  • Involvement of both upper and lower face (including forehead)
  • Absence of other neurologic findings

• Red flags requiring further investigation:

  • Bilateral facial weakness (rare in Bell's palsy)
  • Gradual onset over >72 hours
  • Other neurologic deficits
  • Vesicular rash (suggesting Ramsay Hunt syndrome)
  • History of cancer or trauma

Treatment Algorithm

First-line Treatment (Strong Recommendation)

• Oral corticosteroids within 72 hours of symptom onset 1, 2
  • Adults (≥16 years): Prednisone 60 mg daily for 5 days, followed by 5-day taper OR prednisolone 50 mg daily for 10 days
  • Children: Consider corticosteroids with caregiver involvement in decision-making (evidence less clear) 1, 3

Antiviral Therapy (Optional)

• Do not prescribe antiviral therapy alone (Strong recommendation against) 1, 4
• May consider adding antiviral therapy to corticosteroids within 72 hours of symptom onset (Option) 1, 5
  • Valacyclovir 1 g three times daily for 7 days OR
  • Acyclovir 400 mg five times daily for 10 days

Eye Protection (Strong Recommendation)

• Implement eye protection for all patients with impaired eye closure 1
  • Artificial tears/lubricating eye drops during the day
  • Lubricating eye ointment at night
  • Eye patch or tape eyelid closed at night if unable to close eye completely

Special Considerations

• Pregnant women: Treatment should be individualized, weighing risks and benefits of corticosteroids
• Diabetes, morbid obesity, previous steroid intolerance: Use caution with corticosteroids
• Elderly patients: May particularly benefit from combined therapy (steroids plus antivirals) 6

Follow-up Recommendations

Refer to a facial nerve specialist if:

• New or worsening neurologic findings at any point
• Ocular symptoms developing at any point
• Incomplete facial recovery 3 months after initial symptom onset 1

Prognosis

• Without treatment: ~70% of patients with complete paralysis recover fully within 6 months
• With corticosteroid treatment: ~83% recovery at 3 months, ~94% recovery at 9 months 4
• Children and pregnant women: Up to 90% complete spontaneous recovery 2

Common Pitfalls to Avoid

1. Delayed treatment: Corticosteroids are most effective when started within 72 hours
2. Using antivirals alone: Not effective as monotherapy
3. Neglecting eye protection: Critical to prevent corneal damage
4. Routine laboratory testing or imaging: Not recommended for typical presentation 1
5. Missing alternative diagnoses: Bell's palsy is a diagnosis of exclusion

The evidence strongly supports early corticosteroid treatment as the cornerstone of Bell's palsy management in the emergency setting, with eye protection being essential for patients with impaired eye closure.