From the Guidelines
The current best practice for acute Bell's palsy is to start oral corticosteroids within 72 hours of symptom onset, as this has been shown to significantly improve facial nerve functional recovery and reduce the risk of long-term sequelae 1, 2.
Key Recommendations
- Oral steroids should be prescribed within 72 hours of symptom onset for Bell’s palsy patients 16 years and older, with a recommended regimen of prednisone 60 mg daily for 5 days followed by a 5-day taper (50 mg, 40 mg, 30 mg, 20 mg, 10 mg) 1, 3.
- Antiviral therapy, such as valacyclovir 1000 mg three times daily for 7 days, may be added in cases of severe palsy, although the evidence for its benefit is less robust than for steroids alone 4.
- Eye protection is crucial to prevent corneal damage, with artificial tears used during the day and eye ointment with eye patching at night if the eye cannot close completely 5.
- Patients should be reassessed after 3 weeks, and if no improvement is seen, further investigation with MRI may be warranted to rule out other causes 5.
Rationale
The use of oral corticosteroids within 72 hours of symptom onset has been consistently shown to improve outcomes in Bell's palsy patients, with high-quality randomized controlled trials demonstrating a significant reduction in the risk of long-term sequelae and improvement in facial nerve functional recovery 1, 2. While antiviral therapy may be considered in cases of severe palsy, the evidence for its benefit is less clear, and it should not be used as a replacement for oral steroids 4. Eye protection and follow-up care are also essential components of management, as they can help prevent complications and ensure optimal recovery 5.
From the Research
Diagnosis and Treatment
- The diagnosis of Bell's palsy is based on exclusion, and a thorough history and physical examination are essential 6, 7, 8, 9.
- Corticosteroids are the mainstay of treatment and should be initiated within 72 hours of symptom onset 6, 7, 8, 9.
- The recommended oral corticosteroid regimen is prednisone, 50 to 60 mg per day for five days, followed by a five-day taper 7.
- Antiviral therapy, such as valacyclovir or acyclovir, may be associated with corticosteroids in patients with severe and early-onset disease, and may reduce rates of synkinesis 7, 9, 10.
- Antiviral therapy alone is not recommended, as it has been shown to be ineffective 7, 10.
- Physical therapy may be beneficial in patients with more severe paralysis 7.
Prognosis and Outcomes
- The overall prognosis for Bell's palsy is good, with more than two-thirds of patients experiencing complete spontaneous recovery 7.
- The rate of complete recovery is up to 90% for children and pregnant women 7.
- Early recognition and treatment with corticosteroids can improve outcomes, and late referrals may require more complex reconstructions 8.
- The combination of antivirals and corticosteroids may reduce sequelae of Bell's palsy, such as motor synkinesis or crocodile tears 10.
Management and Referral
- A thorough ENT and neurological clinical examination is recommended to confirm the diagnosis of Bell's palsy 9.
- MRI with gadolinium enhancement and ENMG may be used to explore the entire course of the facial nerve and assess prognosis for recovery 9.
- Early referral for facial reanimation may be necessary for patients with severe Bell's palsy 8.
- Surgical facial nerve decompression is not recommended, as there is no evidence that it provides benefit 6, 9.