What is the management of Bell's palsy, including drug dosages?

Management of Bell's Palsy

The first-line treatment for Bell's palsy is oral corticosteroids (prednisone 50-60 mg daily for 5 days followed by a 5-day taper), which should be initiated within 72 hours of symptom onset to significantly improve recovery rates. 1, 2

Diagnosis and Initial Assessment

• Bell's palsy is characterized by acute onset of unilateral facial weakness/paralysis involving the forehead without other neurologic abnormalities
• Diagnostic approach:
  • Focus on specific neurological findings with targeted testing based on clinical suspicion
  • Complete cranial nerve assessment is essential
  • Laboratory testing and imaging are not routinely required for diagnosis 1, 2
  • Consider Lyme disease serology in endemic areas when clinically indicated 1

Pharmacological Management

Corticosteroids

• Primary treatment: Oral prednisone 50-60 mg daily for 5 days followed by a 5-day taper 2
• Start within 72 hours of symptom onset for maximum effectiveness
• Significantly improves recovery rates at both 3 months (83.0% vs 63.6%) and 9 months (94.4% vs 81.6%) 3, 4
• Number needed to treat (NNT) for one additional complete recovery: 6 at 3 months, 8 at 9 months 4

Antiviral Therapy

• Optional adjunctive treatment, offers minimal additional benefit when combined with steroids 1
• Recommended antivirals if used:
  • Valacyclovir: 1 g three times daily for 7 days, OR
  • Acyclovir: 400 mg five times daily for 10 days 2
• Antiviral monotherapy is ineffective and not recommended 2, 3, 4
• May reduce rates of synkinesis (involuntary co-contraction of facial muscles) when combined with steroids 2

Eye Protection

• Crucial for patients with impaired eye closure to prevent corneal damage 1
• Management includes:
  • 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
• Consider referral if symptoms persist beyond 3 months

Special Considerations

Dosing Considerations

• Recent evidence suggests high-dose corticosteroids (≥80 mg) may be more effective than standard doses (40-60 mg), showing decreased non-recovery at 6 months (OR = 0.17,95% CI = 0.05-0.56) 5
• However, high-dose therapy may be associated with more adverse events (5.8% reported transient elevated liver enzymes and fecal occult blood) 5

Persistent Symptoms

• For patients with dysphagia, provide supportive care and refer to a facial nerve specialist if swallowing difficulties persist beyond 3 months 1
• For persistent facial weakness, consider:
  • Extended physical therapy
  • Referral to specialist for potential Botox injections 6

Prognosis

• Overall prognosis is good with appropriate treatment
• More than two-thirds of patients experience complete spontaneous recovery
• Recovery rates are higher (up to 90%) in children and pregnant women 2
• Early treatment with corticosteroids significantly improves recovery rates 3, 4

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours of symptom onset
• Using antiviral therapy alone without corticosteroids
• Neglecting eye protection in patients with incomplete eye closure
• Failing to distinguish Bell's palsy from other causes of facial weakness (stroke, Lyme disease)
• Not referring patients with persistent symptoms beyond 3 months to specialists