What is the recommended treatment for Bell's palsy?

Bell's Palsy Treatment

Oral corticosteroids (prednisone 60-80mg daily for 7 days with taper) started within 72 hours of symptom onset are strongly recommended as first-line treatment for Bell's palsy. 1

First-Line Treatment

• Corticosteroid therapy:

  • Dosage: Prednisone 60-80mg daily for 7 days followed by taper
  • Timing: Must be started within 72 hours of symptom onset
  • Efficacy: Improves recovery rates from 70% to 94% 1
  • Evidence strength: High-quality evidence with strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery 1

• Contraindications to steroids:

  • Diabetes
  • Morbid obesity
  • Previous steroid intolerance 1

Antiviral Therapy

• Antiviral agents (valacyclovir or acyclovir) may be offered as an optional addition to steroid therapy
• Evidence for benefit is mixed (RR 0.75,95% CI 0.56-1.00) 1
• Not recommended as monotherapy (ineffective when used alone) 2
• Potential options if used:
  • Valacyclovir: 1g three times daily for 7 days
  • Acyclovir: 400mg five times daily for 10 days 2

Mandatory Eye Protection

For patients with impaired eye closure:

• Artificial tears during the day
• Lubricating ophthalmic ointments at night
• Eye patching or taping
• Moisture chambers
• Sunglasses for daytime protection 1

Monitor for symptoms such as:

• Burning
• Itching
• Eye irritation
• Vision changes
• Pain 1

Treatment Algorithm

1. Confirm diagnosis of Bell's palsy (acute unilateral facial weakness/paralysis including forehead)
2. Assess symptom onset timing:
   • If within 72 hours: Start oral corticosteroids immediately
   • If beyond 72 hours: Benefits diminish but may still consider steroids
3. Evaluate for contraindications to steroids
4. Implement eye protection measures if eye closure is impaired
5. Consider optional antiviral therapy in addition to steroids
6. Assess recovery at 3 months:
   • If incomplete recovery: Refer to facial nerve specialist
   • Consider physical therapy for patients with chronic facial paralysis

Prognosis and Follow-up

• More than two-thirds of patients have complete spontaneous recovery without treatment 1
• With steroid treatment, complete recovery rates increase to 94% 1
• Children and pregnant women have higher natural recovery rates (up to 90%) 1, 2
• Patients should be reassessed or referred to a specialist if:
  • New or worsening neurologic findings develop
  • Ocular symptoms occur
  • Incomplete facial recovery after 3 months 1

Special Considerations

• The House-Brackmann scale is 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

• Physical therapy may be beneficial for patients with more severe paralysis or chronic facial weakness, though evidence is limited 1, 2

Common Pitfalls to Avoid

1. Delaying steroid treatment beyond 72 hours (significantly reduces effectiveness)
2. Using antiviral therapy alone (not effective)
3. Neglecting eye protection measures (can lead to corneal damage)
4. Failing to reassess patients with incomplete recovery after 3 months
5. Not addressing psychological impacts of facial asymmetry

Recent research suggests high-dose corticosteroids (≥80mg) may be more effective than standard doses (40-60mg) in reducing non-recovery at 6 months 3, though this finding requires further validation with more robust methodology before changing current guidelines.