What is the treatment for Bell's palsy?

Treatment of Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset for patients with Bell's palsy, as they significantly improve facial nerve recovery and decrease recovery time. 1

First-Line Treatment

Adults (16 years and older)

• Oral corticosteroid regimen:
  • Prednisolone 25 mg twice daily for 10 days, OR
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
  • Must be initiated within 72 hours of symptom onset for maximum benefit
  • Significantly improves recovery rates (83% vs 63.6% at 3 months, 94.4% vs 81.6% at 9 months) 1

Children

• Less conclusive evidence for treatment
• Higher rates of spontaneous recovery than adults (up to 90%) 2
• Oral steroids may be considered based on:
  • Presumed similar disease process as adults
  • Generally favorable benefit-harm ratio 1
  • Requires significant caregiver involvement in decision-making

Antiviral Therapy

Antiviral Monotherapy

• Not recommended as sole treatment for Bell's palsy 1
• No better than placebo for facial nerve recovery

Combination Therapy (Steroids + Antivirals)

• May be offered as an option within 72 hours of symptom onset 1
• Potential small additional benefit in facial nerve recovery
• Recommended antivirals if used:
  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 2
• May reduce rates of synkinesis (involuntary co-contraction of facial muscles) 2

Additional Management Considerations

Eye Care

• Critical to prevent corneal damage in patients with incomplete eye closure
• May require artificial tears, eye ointment, and/or eye patch

Physical Therapy

• May be beneficial for patients with more severe paralysis 2

Imaging

• Not routinely indicated at initial diagnosis
• Consider MRI with contrast of the entire facial nerve course if:
  • Atypical presentation (trauma, tumor history)
  • Paralysis fails to recover in expected timeframe
  • Paralysis worsens
  • Second paralysis on same side
  • Isolated branch paralysis
  • Associated with other cranial nerve involvement
  • No recovery after 3 months 1

Prognosis

• Overall good prognosis even without treatment
• More than two-thirds of patients with typical Bell's palsy have complete spontaneous recovery 2
• Complete recovery rates:
  • 70% in patients with complete paralysis within 6 months
  • Up to 94% in patients with incomplete paralysis 1
  • Up to 90% in children and pregnant women 2

Common Pitfalls to Avoid

1. Delaying steroid treatment beyond 72 hours of symptom onset
2. Using antiviral therapy alone without steroids
3. Failing to recognize atypical features requiring further investigation
4. Neglecting eye protection measures in patients with incomplete eye closure
5. Missing alternative diagnoses (Bell's palsy is a diagnosis of exclusion)

Remember that Bell's palsy is a diagnosis of exclusion requiring careful elimination of other causes of facial paresis or paralysis 1. Early intervention with appropriate treatment significantly improves outcomes and quality of life.