What is the treatment for facial paralysis, specifically Bell's palsy?

Treatment of Bell's Palsy

For Bell's palsy, oral corticosteroids (prednisone 50-60 mg daily for 5 days followed by a 5-day taper) are strongly recommended as first-line treatment and should be started as early as possible for optimal recovery. 1, 2

Diagnostic Approach

Before initiating treatment, ensure the diagnosis is correct:

• Confirm acute onset of unilateral facial weakness/paralysis involving the forehead
• Rule out other neurological abnormalities that would suggest alternative diagnoses
• Note that routine laboratory testing and imaging are not required for typical Bell's palsy 2
• Be alert for atypical features suggesting another diagnosis:
  • Gradual/progressive onset (not sudden)
  • Absence of forehead involvement
  • Other neurological symptoms
  • Bilateral facial weakness

Treatment Algorithm

First-line Treatment

• Oral corticosteroids: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 2
  • Start as early as possible for maximum benefit
  • High-quality evidence shows significantly improved recovery rates 1

Additional Treatment Options

• Antiviral therapy: Optional addition to steroids
  • Valacyclovir 1g three times daily for 7 days OR
  • Acyclovir 400mg five times daily for 10 days
  • Provides minimal additional benefit (RR 0.75,95% CI 0.56-1.00) 1, 2
  • Not recommended as monotherapy 2

Critical Eye Protection Measures

• For patients with impaired eye closure:
  • Artificial tears during the day
  • Lubricating ointment at night
  • Tape eyelids closed if necessary
  • Refer to ocular specialist for persistent eye symptoms 1

Rehabilitation

• Physical therapy: Particularly beneficial for patients with more severe paralysis 1, 2
  • Helps address synkinesis (involuntary co-contraction of facial muscles)
  • Improves facial symmetry

Special Populations

• Children and pregnant women have higher spontaneous recovery rates (up to 90%) 2
• Patients with diabetes, hypertension, and obesity have higher risk 3, 4

When to Refer

• Refer to a facial nerve specialist for:
  • Incomplete recovery with residual facial weakness
  • Worsening symptoms
  • Persistent dysphagia beyond 3 months
  • Development of synkinesis 1

Prognosis

• More than two-thirds of patients with typical Bell's palsy experience complete spontaneous recovery 2
• Early treatment with corticosteroids improves outcomes
• Untreated or delayed treatment may increase risk of permanent facial impairment 4

Common Pitfalls to Avoid

1. Misdiagnosing other causes of facial paralysis as Bell's palsy (always confirm typical presentation) 5
2. Delaying corticosteroid treatment (should be started as early as possible)
3. Using antivirals alone without steroids 2
4. Neglecting eye protection measures in patients with incomplete eye closure
5. Failing to recognize atypical features that warrant further investigation