What is the immediate treatment for a patient diagnosed with Bell's palsy?

Immediate Treatment for Bell's Palsy

Oral corticosteroids should be started immediately for all patients diagnosed with Bell's palsy, ideally within 72 hours of symptom onset. 1

First-Line Treatment

• Corticosteroid regimen:

  • Prednisone 50 mg daily for 5 days followed by a 5-day taper 1, 2
  • Treatment should be initiated as soon as possible, preferably within 72 hours of symptom onset
  • High-quality evidence shows significantly improved recovery rates with early steroid administration 1

• Antiviral therapy:

  • Optional addition to corticosteroids 1
  • May be considered to potentially reduce rates of synkinesis (involuntary co-contraction of facial muscles) 2
  • Options include:
    • Valacyclovir 1 g three times daily for 7 days 2
    • Acyclovir 400 mg five times daily for 10 days 2
  • Not recommended as monotherapy as it shows no significant benefit when used alone 1, 3, 4

Critical Eye Protection Measures

• For patients with impaired eye closure:
  • Artificial tears during daytime (every 1-2 hours)
  • Lubricating ointment at night
  • Tape eyelids closed if necessary
  • Consider eye patch for protection 1

Evidence Analysis

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends oral corticosteroids based on high-quality evidence 1. This is supported by multiple randomized controlled trials showing significant improvement in recovery rates with corticosteroids.

A landmark 2009 randomized controlled trial (BELLS study) demonstrated that at 3 months, 83.0% of patients receiving prednisolone had complete recovery compared to only 63.6% in the no-prednisolone group (NNT = 6) 3. At 9 months, recovery rates were 94.4% for prednisolone versus 81.6% for no prednisolone 3, 4.

The evidence for antivirals is less compelling. The same trials showed no significant benefit of acyclovir alone (71.2% recovery with acyclovir vs. 75.7% without) 3, 4. However, some studies suggest a potential benefit of combination therapy in reducing synkinesis 2.

Common Pitfalls and Caveats

• Delayed treatment: Initiation of corticosteroids beyond 72 hours may reduce effectiveness
• Inadequate eye protection: Failure to protect the eye can lead to corneal damage and vision loss
• Misdiagnosis: Ensure Bell's palsy is correctly diagnosed (acute unilateral facial weakness including the forehead, without other neurological findings)
• Antiviral monotherapy: Using antivirals without steroids is ineffective and not recommended 1, 2
• Follow-up: Regular monitoring is essential; refer to a facial nerve specialist if incomplete recovery after 3 months 1

Special Populations

• Diabetic patients: Monitor blood glucose closely when using corticosteroids
• Pregnant women: Generally have excellent prognosis (up to 90% complete recovery) 2
• Children: Also have high spontaneous recovery rates (up to 90%) 2

Follow-up Care

• Monitor recovery progress regularly
• Consider referral to:
  • Facial nerve specialist if incomplete recovery after 3 months
  • Neurologist for new or worsening neurologic findings
  • Ophthalmologist for persistent ocular symptoms 1
• Physical therapy may benefit patients with more severe paralysis 2