Bell's Palsy: Signs, Symptoms, and Treatment
Oral corticosteroids should be administered within 72 hours of symptom onset as the primary treatment for Bell's palsy, with eye protection measures implemented immediately for patients with incomplete eye closure. 1
Signs and Symptoms
Bell's palsy presents with:
- Acute onset of unilateral facial weakness or paralysis (developing over 1-3 days)
- Involvement of the forehead muscles (distinguishing it from central causes)
- No other neurologic abnormalities
- Symptoms typically peak within the first week 2, 3
Key clinical features include:
- Inability to close the eye on affected side
- Drooping of the mouth corner
- Flattening of nasolabial fold
- Decreased or absent forehead wrinkling
- Possible hyperacusis (increased sensitivity to sound)
- Possible altered taste sensation
- Possible pain behind the ear
Diagnosis
Bell's palsy is a diagnosis of exclusion. A thorough history and physical examination focusing on facial nerve function should be performed to rule out other causes of facial weakness 1.
- Routine laboratory testing and diagnostic imaging are not recommended unless other conditions are suspected 1
- Consider testing for diabetes mellitus and Lyme disease when indicated by history or risk factors 3
Treatment Algorithm
1. First-Line Treatment: Corticosteroids
- Initiate oral corticosteroids within 72 hours of symptom onset for patients 16 years and older 1
- Recommended regimen: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 2
- High-quality evidence shows significantly improved recovery rates with early steroid administration 1
2. Antiviral Therapy (Optional)
- May be added to steroids but should not be used as monotherapy 1, 2
- Recommended antivirals:
- Valacyclovir: 1 g three times daily for 7 days, OR
- Acyclovir: 400 mg five times daily for 10 days 2
- Evidence shows minimal additional benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00) 1
- May reduce rates of synkinesis (involuntary co-contraction of facial muscles) 2
3. Eye Protection (Critical)
For patients with incomplete eye closure:
- Artificial tears during the day
- Ocular ointment at night
- Eye patching or taping when necessary
- These measures are crucial for preventing corneal damage 1
4. Physical Therapy
- May be beneficial for patients with more severe paralysis 2
- Focuses on maintaining range of motion and preventing contractures 1
Prognosis
- Without treatment: 70-80% of patients recover spontaneously 3
- With early corticosteroid treatment: Recovery rates improve significantly (83% at 3 months, 94.4% at 9 months) 4
- Children and pregnant women: Up to 90% complete recovery rate 2
High-Risk Populations
Bell's palsy occurs more frequently in:
- People aged 15-45 years
- Patients with diabetes mellitus
- Individuals with upper respiratory infections
- Those with compromised immune systems
- Pregnant women, including those with severe preeclampsia 1
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours of symptom onset significantly diminishes benefits 1
- Using antiviral medication alone is ineffective and not recommended 1, 2
- Neglecting eye protection in patients with incomplete eye closure can lead to corneal damage 1
- Failing to reevaluate patients who develop new/worsening neurologic findings or have incomplete recovery after 3 months 1
- Not considering patient-specific factors such as diabetes, pregnancy, or previous steroid intolerance when prescribing treatment 1
Follow-up
Patients should be reevaluated if:
- They develop new or worsening neurologic findings
- They have incomplete recovery after 3 months 1
For patients with persistent or severe Bell's palsy, consider referral for reconstructive procedures 1.