What is the treatment for Bell's palsy?

Treatment of Bell's Palsy

Oral corticosteroids are strongly recommended as first-line treatment for Bell's palsy and should be initiated within 72 hours of symptom onset for optimal outcomes. 1, 2

Diagnosis and Assessment

• Bell's palsy is characterized by acute onset of unilateral, lower motor neuron weakness of the facial nerve without an identifiable cause
• Assess severity using the House-Brackmann scale (grades 1-6):
  • Grade 1: Normal facial function
  • Grade 2: Mild dysfunction (slight asymmetry)
  • Grade 3: Moderate dysfunction (obvious but not disfiguring)
  • Grade 4: Moderately severe dysfunction (obvious weakness/disfiguring)
  • Grade 5: Severe dysfunction (barely perceptible movement)
  • Grade 6: Total paralysis 1

Treatment Algorithm

First-Line Treatment

• Oral corticosteroids: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 2
  • Should be started within 72 hours of symptom onset
  • Treatment within 48 hours shows significantly higher complete recovery rates (66-76% vs. 51-58% without prednisolone) 3
  • Patients aged 40+ years benefit more significantly from corticosteroid treatment 3

Adjunctive Treatment Options

• Antiviral therapy: May be considered in combination with corticosteroids
  • Options include valacyclovir (1g three times daily for 7 days) or acyclovir (400mg five times daily for 10 days) 2
  • Provides minimal additional benefit (RR 0.75,95% CI 0.56-1.00) 1
  • Not recommended as monotherapy 2

Supportive Care

• Eye protection for patients with impaired eye closure:
  • Artificial tears during daytime
  • Lubricating ointment at night
  • Taping eyelids closed if necessary 1
• Physical therapy may be beneficial for patients with more severe paralysis 2

Special Considerations

• High-dose vs. standard-dose corticosteroids: Recent evidence suggests high-dose corticosteroids (≥80 mg) may be more effective than standard doses (40-60 mg) with decreased non-recovery at 6 months (OR = 0.17,95% CI = 0.05-0.56) 4

  • However, this finding comes with serious risk of bias and requires further research

• Timing matters: Treatment efficacy decreases with time:

  • Within 24 hours: 66% complete recovery with prednisolone vs. 51% without
  • 25-48 hours: 76% complete recovery with prednisolone vs. 58% without
  • 49-72 hours: No significant difference 3

• Age considerations:

  • Patients ≥40 years show significantly higher recovery rates with prednisolone
  • Patients <40 years show less synkinesis with prednisolone treatment 3

Follow-Up and Referral

• Regular follow-up to monitor recovery progress
• Refer to facial nerve specialist if:
  • Incomplete recovery after 3 months
  • Persistent swallowing difficulties
  • New or worsening neurological findings 1

Common Pitfalls to Avoid

• Delay in treatment initiation: Corticosteroid efficacy decreases significantly after 48 hours 3
• Using antivirals alone: Not effective as monotherapy 2
• Inadequate eye protection: Can lead to corneal damage in patients with impaired eye closure 1
• Missing other causes: Bell's palsy is a diagnosis of exclusion; ensure thorough evaluation to rule out other etiologies 5

Prognosis

• Overall prognosis is good with >2/3 of patients experiencing complete spontaneous recovery
• Children and pregnant women have up to 90% complete recovery rates 2
• Early corticosteroid treatment significantly improves chances of complete recovery at 3 and 9 months (94.4% with prednisolone vs. 81.6% without at 9 months) 6