What is the treatment for Bell's palsy?

Treatment for Bell's Palsy

Oral corticosteroids within the first 72 hours of symptom onset are the cornerstone of treatment for Bell's palsy, with a recommended dose of prednisone 60-80mg daily for 7 days followed by a gradual taper. 1

First-Line Treatment: Corticosteroids

• Oral corticosteroids significantly improve recovery rates from 70% to 94% 1
• Controlled trials demonstrate that prednisolone treatment results in 83% recovery of facial nerve function at 3 months, compared to only 63.6% with placebo 1
• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends early steroid administration 1
• Specific regimen options:
  • Prednisone 60-80mg daily for 7 days with gradual taper 1
  • Alternative: Prednisone 50-60mg daily for 5 days followed by a 5-day taper 2

Antiviral Therapy: Optional Add-on

• Antiviral therapy may be offered as an optional complement to steroid therapy, but evidence of additional benefit is mixed 1
• Combination therapy with corticosteroids and antivirals may reduce rates of synkinesis (involuntary co-contraction of facial muscles due to misdirected nerve regrowth) 2
• Important: Antiviral therapy alone is ineffective and not recommended 1, 2
• Antiviral options when used with steroids:
  • Valacyclovir 1g three times daily for 7 days 1, 2
  • Acyclovir 400mg five times daily for 10 days 1, 2

Mandatory Eye Protection

• Eye protection is mandatory for patients with impaired eye closure 1
• Options include:
  • Artificial tears and lubricating eye drops/ointments
  • Eye patches or adhesive tape
  • Humid chambers
  • Sunglasses for daytime protection 1

Physical Therapy Considerations

• May be beneficial for patients with more severe facial paralysis 1, 2
• Can include:
  • Superficial local heat therapy
  • Massage
  • Facial exercises
  • Electrical stimulation
  • Biofeedback training 1
• Note: Evidence for physical therapy is inconclusive and standardized protocols are lacking 1

Follow-up and Evaluation

• Patients should be reevaluated if they present with:
  • New or worsening neurological findings
  • Ocular symptoms
  • Incomplete facial recovery after 3 months 1
• The House-Brackmann scale (grades 1-6) should be used to quantify facial nerve function 1
• Referral to a facial nerve specialist should be considered for patients with incomplete recovery 1

Special Considerations

• Overall prognosis is good with more than two-thirds of patients experiencing complete spontaneous recovery 1, 2
• Children and pregnant women have even better outcomes, with up to 90% achieving complete recovery 1, 2
• Early treatment with corticosteroids significantly improves recovery rates 1
• Consider psychological support for patients with persistent facial weakness who may experience depression, social interaction challenges, or stigmatization 1

Common Pitfalls to Avoid

1. Delayed treatment: Starting corticosteroids after 72 hours reduces effectiveness
2. Using antivirals alone: Not effective as monotherapy
3. Neglecting eye protection: Can lead to corneal damage in patients with incomplete eye closure
4. Missing other causes: Bell's palsy is a diagnosis of exclusion; consider other etiologies if atypical features present
5. Inadequate follow-up: Patients with incomplete recovery at 3 months require specialist referral

When to Consider Referral

• Neurologist: For patients with new or worsening neurologic findings at any point 1
• Ophthalmologist: For patients with ocular symptoms 1
• Facial nerve specialist: For incomplete facial recovery after 3 months 1
• Consider MRI (with and without contrast) for patients with atypical presentations 1