What is the assessment and treatment plan for a patient with Bell's palsy?

Assessment and Management of Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset for Bell's palsy patients 16 years and older to significantly improve facial nerve recovery. 1

Diagnosis and Assessment

Definition and Clinical Presentation

• Bell's palsy is an acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without an identifiable cause 1
• Characterized by rapid onset of unilateral facial weakness or paralysis involving the forehead 2
• May cause significant temporary oral incompetence and inability to close the eyelid 1

Diagnostic Approach

• Bell's palsy is a diagnosis of exclusion requiring careful elimination of other causes 1
• Thorough history and physical examination are essential to exclude identifiable causes of facial paresis/paralysis 1
• Look for key features:
  • Rapid onset (<72 hours) 1
  • Unilateral involvement (bilateral Bell's palsy is rare) 1
  • No other neurological abnormalities 2

Differential Diagnosis

• Other conditions causing facial paralysis include:
  • Stroke, brain tumors, tumors of the parotid gland or infratemporal fossa 1
  • Cancer involving the facial nerve 1
  • Systemic and infectious diseases (zoster, sarcoidosis, Lyme disease) 1
  • HIV/AIDS, Guillain-Barré syndrome, multiple cranial neuropathies, syphilis 1

Diagnostic Testing

• Routine laboratory testing is NOT recommended 1
• Routine diagnostic imaging is NOT recommended 1
• Electrodiagnostic testing is NOT recommended for patients with incomplete facial paralysis 1
• Electrodiagnostic testing may be offered to patients with complete facial paralysis 1

Treatment Plan

First-Line Treatment

• Oral corticosteroids within 72 hours of symptom onset for patients 16 years and older 1
• Recommended regimen:
  • Prednisolone 50 mg daily for 10 days, OR
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• Strong evidence supports corticosteroid use:
  • 83% recovery at 3 months with prednisolone vs 63.6% with placebo 1
  • 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1

Antiviral Therapy

• Antiviral monotherapy is NOT recommended 1
• Combination therapy (antivirals plus steroids) may be offered within 72 hours of symptom onset 1
• Options for antivirals if used in combination with steroids:
  • Valacyclovir 1 g three times daily for 7 days 2, 3
  • Acyclovir 400 mg five times daily for 10 days 2

Eye Protection

• Implement eye protection for patients with impaired eye closure 1
• Critical to prevent corneal exposure, dryness, and potential injury 1

Special Populations

Children

• Prognosis of untreated Bell's palsy in children is better than in adults 1
• Children show higher rates of spontaneous recovery 1
• Benefit of corticosteroid treatment in children is inconclusive 1

Elderly Patients

• Elderly patients may particularly benefit from treatment 3
• One study showed 100% complete recovery in treated patients over 60 years old compared to only 42% in untreated patients 3

Follow-up and Referral

When to Reassess or Refer to a Specialist

• New or worsening neurologic findings at any point 1
• Ocular symptoms developing at any point 1
• Incomplete facial recovery 3 months after initial symptom onset 1

Prognosis

• More than two-thirds of patients with typical Bell's palsy have complete spontaneous recovery 2
• For children and pregnant women, the rate of complete recovery is up to 90% 2
• With corticosteroid treatment, recovery rates improve significantly 1, 3

Important Considerations and Caveats

• Treatment with corticosteroids is most effective when started within 72 hours of symptom onset 1
• The benefit of treatment after 72 hours is less clear 1
• High-dose corticosteroids may be more effective than standard doses, but more research is needed 4
• Imaging should be considered for atypical presentations, including:
  • Second paralysis on the same side
  • Paralysis of isolated branches of the facial nerve
  • Paralysis associated with other cranial nerve involvement
  • No sign of recovery after 3 months 1
• MRI with and without contrast is the imaging test of choice when indicated 1