How is Bell's palsy managed?

Management of Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset for all patients with Bell's palsy aged 16 years and older to improve facial nerve recovery. 1

Initial Assessment and Diagnosis

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 1. Before initiating treatment:

• Confirm diagnosis by excluding other causes of facial weakness
• Assess severity of facial weakness (complete vs. incomplete paralysis)
• Document eye closure ability
• Note presence of associated symptoms (ear pain, taste disturbance, hyperacusis)

Treatment Algorithm

First-line Treatment (within 72 hours of onset)

1. For adults (≥16 years):

   • Oral corticosteroids: Prednisolone 50-60 mg daily for 5 days followed by a 5-day taper 1, 2
   • Alternative regimen: Prednisolone 25 mg twice daily for 10 days 1

2. For children:

   • Evidence for steroid use is less conclusive
   • May consider steroids with shared decision-making with caregivers 1
   • Higher spontaneous recovery rates (up to 90%) are observed in children 2

Optional Adjunctive Treatment

• Antiviral therapy may be offered in addition to steroids within 72 hours of symptom onset 1
  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 2
  • Note: Antiviral monotherapy is NOT recommended 1, 3

Critical Eye Protection

• All patients with impaired eye closure must receive eye protection 1
  • Frequent lubricating eye drops during the day
  • Lubricating ointment at night
  • Consider eye patching or taping if needed
  • Moisture chamber or polyethylene cover may be used

Follow-up and Monitoring

• Reassess patients who do not show improvement within 3 months 1
• Consider referral to facial nerve specialist if:
  • No improvement after 3 months
  • Incomplete recovery after 6 months
  • Development of synkinesis (involuntary facial movements)
  • Severe or persistent eye symptoms

Evidence-Based Outcomes

• With corticosteroid treatment, 83% of patients recover facial function by 3 months and 94.4% by 9 months 1, 3
• Without treatment, only 63.6% recover by 3 months and 81.6% by 9 months 1, 3
• Combination therapy with antivirals may provide small additional benefit in facial nerve recovery, though evidence is less robust 1, 4

Important Clinical Considerations

• Treatment timing is critical: Corticosteroids must be started within 72 hours of symptom onset for maximum benefit 1, 3
• Avoid antiviral monotherapy: Studies consistently show no benefit when antivirals are used alone 1, 3
• Special populations:
  • Pregnant women: Up to 90% recovery rate; treatment should be individualized 2, 5
  • Diabetic patients: Use steroids with caution and monitor blood glucose 1
  • Elderly patients: May benefit particularly from combination therapy 4

Electrodiagnostic Testing

• Not recommended for patients with incomplete facial paralysis 1
• May be considered in patients with complete paralysis who show no improvement after 3 months 1

The evidence strongly supports early corticosteroid treatment as the cornerstone of Bell's palsy management, with eye protection being essential for preventing corneal complications in those with impaired eye closure.