What is the immediate treatment for a patient diagnosed with Bell's palsy?

Immediate Treatment for Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset as the first-line treatment for Bell's palsy. 1 This recommendation is based on strong evidence showing significantly improved recovery rates with early steroid administration.

Diagnostic Criteria

Bell's palsy is defined as:

• Acute unilateral facial nerve paresis or paralysis
• Onset in less than 72 hours
• No identifiable cause
• May present with inability to voluntarily move facial muscles on the affected side 2, 1

Treatment Algorithm

First-Line Treatment (Start Immediately)

• Oral corticosteroids within 72 hours of symptom onset:
  • Prednisolone 50 mg daily for 10 days OR
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1

Optional Add-On Treatment

• Antiviral therapy may be considered as an adjunct to corticosteroids (not as monotherapy):
  • Valacyclovir 1 g three times daily for 7 days OR
  • Acyclovir 400 mg five times daily for 10 days 1, 3
  • Note: The evidence for combination therapy shows only a modest additional benefit compared to steroids alone (RR 0.75,95% CI 0.56-1.00) 1

Critical Eye Protection Measures (Start Immediately)

• For patients with impaired eye closure:
  • Frequent lubricating eye drops
  • Ophthalmic ointment (especially at night)
  • Consider moisture chamber or eye taping/patching 1

Evidence for Treatment Efficacy

High-quality evidence supports the use of oral corticosteroids:

• 83% of patients treated with prednisolone recovered facial function at 3 months compared to 63.6% with placebo 1, 4
• The number needed to treat (NNT) to achieve one additional complete recovery is 6 4
• At 9 months, recovery rates were 94.4% for prednisolone compared to 81.6% for no prednisolone 4

Antiviral monotherapy is not effective and should not be used alone:

• No significant difference in recovery rates between aciclovir and placebo groups (71.2% vs 75.7%) 4
• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against antiviral monotherapy 1

Special Considerations

Early Deterioration

• Early deterioration (within first 11-17 days) is a negative prognostic factor
• Complete recovery at 12 months is 45% among patients with early deterioration compared to 73% in those without 5
• Prednisolone significantly improves outcomes even in patients with early deterioration (62% vs 31% complete recovery) 5

Pediatric Patients

• Children show higher spontaneous recovery rates (up to 90%) 1
• Evidence for steroid use in children is less conclusive, but may be considered with caregiver involvement in decision-making 1

Elderly Patients

• Elderly patients may particularly benefit from combination therapy
• One study showed 100% recovery in treated patients over 60 years compared to 42% in untreated controls 6

Referral Criteria

Refer to a facial nerve specialist if:

• No improvement or worsening after 3 months
• New or worsening neurologic findings at any point
• Ocular symptoms developing at any point
• Incomplete facial recovery 3 months after initial presentation 2, 1

Follow-up Recommendations

• Re-evaluate within 2-3 weeks to assess for improvement or deterioration
• Monitor for eye complications at each visit
• Consider electrodiagnostic testing for patients with complete facial paralysis 2