What is the treatment protocol for sudden facial nerve palsy, specifically Bell's palsy?

Treatment Protocol for Sudden Facial Nerve Palsy (Bell's Palsy)

Oral corticosteroids are strongly recommended as first-line treatment for Bell's palsy, specifically prednisone 50-60 mg daily for 5 days followed by a 5-day taper. 1, 2

Diagnostic Approach

Before initiating treatment, confirm Bell's palsy diagnosis through:

• Clinical presentation of acute unilateral facial weakness/paralysis involving the forehead
• Absence of other neurological abnormalities
• No routine laboratory testing or imaging needed for typical presentation 1, 2

Treatment Algorithm

First-Line Treatment

• Corticosteroids: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 1, 2
  • Alternative regimen: Prednisolone 25 mg twice daily for 10 days 3
  • Start within 72 hours of symptom onset for maximum benefit
  • High-quality evidence shows significantly improved recovery rates (NNT = 10) 1, 4

Optional Adjunctive Treatment

• Antiviral therapy: Consider in severe cases or when herpes zoster is suspected 1, 3
  • Options:
    • Valacyclovir 1 g three times daily for 7 days, OR
    • Acyclovir 400 mg five times daily for 10 days 2
  • Evidence shows minimal additional benefit when combined with steroids 1
  • May reduce rates of synkinesis (involuntary co-contraction of facial muscles) 2

Eye Protection (Critical)

• For patients with impaired eye closure:
  • Artificial tears during daytime
  • Lubricating ointment (dexpanthenol) at night
  • Moisture-retaining eye shield for nocturnal use
  • Taping eyelids closed if necessary 1, 3

Management of Complications

For Persistent Symptoms

• Physical therapy: Beneficial for patients with more severe paralysis 2, 5
• Referral to specialist: If no improvement after 3 months 5
• For synkinesis/autonomic dysfunction: Consider botulinum toxin injections 5

Prognosis and Follow-up

• Overall prognosis is good with >2/3 of patients achieving complete spontaneous recovery 2
• Higher recovery rates (up to 90%) in children and pregnant women 2
• Close follow-up is warranted to monitor recovery 5

Common Pitfalls to Avoid

1. Delayed treatment: Corticosteroids should be initiated as soon as possible after symptom onset
2. Neglecting eye protection: Can lead to corneal damage in patients with incomplete eye closure
3. Using antivirals alone: Not effective as monotherapy 2
4. Missing other causes: Remember that 25-40% of facial nerve palsies are not idiopathic 3
5. Inadequate follow-up: Patients without improvement should be referred to specialists

The evidence strongly supports corticosteroids as the cornerstone of Bell's palsy treatment, with antivirals providing possible additional benefit in specific cases. Eye protection is essential to prevent corneal complications during recovery.