What are the treatment guidelines for Bell's palsy in the USA and Europe?

Bell's Palsy Treatment Guidelines in the USA and Europe

Oral corticosteroids should be administered within 72 hours of symptom onset as first-line treatment for Bell's palsy in both USA and European practice. 1

Diagnosis and Assessment

• Bell's palsy is characterized by acute onset unilateral facial weakness/paralysis involving the forehead
• Key diagnostic feature: inability to raise eyebrow or wrinkle forehead on affected side (differentiates from stroke) 1
• House-Brackmann scale recommended to quantify facial nerve function:
  • Grade 1: Normal facial function
  • Grade 2: Mild dysfunction
  • Grade 3: Moderate dysfunction
  • Grade 4: Moderately severe dysfunction
  • Grade 5: Severe dysfunction
  • Grade 6: Total paralysis 1

First-Line Treatment

• Oral corticosteroids: Prednisone 60-80mg daily for 7 days with taper, started within 72 hours of symptom onset 2, 1
  • Strong recommendation based on high-quality evidence
  • Improves recovery rates from 70% (no treatment) to 94% (with steroids) 2
  • Particularly beneficial for elderly patients 3

Antiviral Therapy

• Optional addition to steroid therapy (not recommended as monotherapy) 2, 1
• May be offered within 72 hours of symptom onset 2
• Options include:
  • Valacyclovir 1g three times daily for 7 days 4, 3
  • Acyclovir 400mg five times daily for 10 days 4
• Evidence for benefit is mixed:
  • Some studies show minimal additional benefit when combined with steroids 1
  • Others show improved outcomes with combination therapy 3, 5
  • Large trials found no significant benefit of acyclovir alone or added to prednisolone 6

Eye Protection (Critical)

• Strong recommendation for all patients with impaired eye closure 2, 1
• Options include:
  • Artificial tears and lubricating ophthalmic drops/ointments
  • Eye patching or taping (especially at night)
  • Moisture chambers
  • Sunglasses for daytime protection 2
• Patients should be monitored for symptoms like burning, itching, eye irritation, vision changes, and pain 2
• Severe cases may require ophthalmologic evaluation and consideration of botulinum toxin injections or surgical interventions 2

Physical Therapy

• May be beneficial for patients with more severe paralysis 4
• Consider for maintaining range of motion and preventing contractures 1
• Limited evidence for effectiveness, but low risk of harm

Follow-up and Referral

• Reassess or refer to facial nerve specialist if:
  • New or worsening neurologic findings develop
  • Ocular symptoms occur
  • Incomplete facial recovery after 3 months 1
• Electrodiagnostic testing is not recommended for patients with incomplete facial paralysis 2

Special Populations

• Pregnant women: Treatment should be individualized 2
• Higher natural recovery rates (up to 90%) in children and pregnant women 4
• Contraindications to steroids: Diabetes, morbid obesity, previous steroid intolerance 2

Prognosis

• Overall prognosis is favorable with appropriate treatment
• Complete recovery rates:
  • 70% with no treatment
  • Up to 94% with steroid treatment 2, 1
• Delaying treatment beyond 72 hours diminishes benefits 1

Differences Between USA and European Guidelines

Both USA (American Academy of Otolaryngology-Head and Neck Surgery) and European guidelines align on the core recommendations of early corticosteroid treatment and eye protection, with antiviral therapy as an optional addition. There are no significant differences in the treatment approaches between regions based on the available evidence.