Bell's Palsy Management
Oral corticosteroids should be prescribed within 72 hours of symptom onset as the first-line treatment for Bell's palsy in patients 16 years and older. 1, 2
Diagnostic Approach
- Bell's palsy is defined as acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without an identifiable cause 1
- Routine laboratory testing is not recommended for typical presentations of Bell's palsy 1, 2
- Diagnostic imaging should not be routinely performed for new-onset Bell's palsy 1, 2
- Consider alternative diagnoses if there are atypical features such as bilateral involvement, slow progression, or other neurological symptoms 1, 2
Treatment Algorithm
First-Line Treatment
- Corticosteroid regimen: 1, 2
- Prednisolone 50 mg daily for 10 days, OR
- Prednisone 60 mg daily for 5 days followed by a 5-day taper
- Treatment should be initiated within 72 hours of symptom onset for maximum effectiveness
Antiviral Therapy
- Antiviral monotherapy is NOT recommended and should not be prescribed alone 1, 2, 3
- Combination therapy with oral antivirals plus corticosteroids may be considered as an option 1, 2
- When used in combination with steroids, recommended antiviral regimens include: 2, 3
- Valacyclovir 1 g three times daily for 7 days, OR
- Acyclovir 400 mg five times daily for 10 days
Eye Protection
- Implement eye protection for all Bell's palsy patients with impaired eye closure to prevent corneal damage 1, 2
- Eye protection measures may include: 1, 2
- Artificial tears during the day
- Lubricating ointment at night
- Taping the eye closed
- Moisture chambers
Evidence for Treatment Efficacy
- High-quality randomized controlled trials demonstrate that early treatment with prednisolone significantly improves complete recovery rates: 1, 4
- 83% recovery at 3 months with prednisolone vs. 63.6% with placebo
- 94.4% recovery at 9 months with prednisolone vs. 81.6% with placebo
- Combination therapy may provide additional benefit in some patients: 2, 5
- One study showed 87.5% complete recovery with combination therapy vs. 68% in untreated controls
- Particularly beneficial in elderly patients, with 100% recovery in treated patients over 60 years vs. 41.7% in untreated controls
Follow-up Recommendations
- Reassess or refer to a facial nerve specialist if: 1, 2
- New or worsening neurologic findings develop at any point
- Ocular symptoms develop at any point
- Incomplete facial recovery persists 3 months after initial symptom onset
- Electrodiagnostic testing is not recommended for patients with incomplete facial paralysis 1
- Electrodiagnostic testing may be considered for patients with complete facial paralysis 1
Special Populations
- For children: Evidence for steroid use is less conclusive as children show higher rates of spontaneous recovery than adults 1, 2
- For pregnant women: Recovery rates are higher (up to 90%) even without treatment 3
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours, which reduces effectiveness 2, 4
- Using antiviral therapy alone, which is ineffective 1, 2, 6
- Failing to provide adequate eye protection for patients with impaired eye closure 1, 2
- Ordering unnecessary laboratory tests or imaging studies for typical presentations 1, 2