What is the management protocol for Bell's palsy?

Bell's Palsy Management Protocol

Oral corticosteroids should be prescribed within 72 hours of symptom onset for Bell's palsy patients 16 years and older as the primary treatment. 1, 2

Initial Assessment and Diagnosis

• Bell's palsy is characterized by acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without an identifiable cause 1, 3
• Thorough history and physical examination are essential to exclude other causes of facial weakness 3
• Routine laboratory testing is NOT recommended for typical presentations 1, 3
• Routine diagnostic imaging is NOT recommended for new-onset Bell's palsy 1, 3

First-Line Treatment

• Prescribe oral steroids within 72 hours of symptom onset for patients 16 years and older 1, 2
• Recommended regimen: Prednisolone 50 mg daily for 10 days OR Prednisone 60 mg daily for 5 days followed by a 5-day taper 2, 4
• Strong evidence supports corticosteroid use with 83% recovery at 3 months with prednisolone vs 63.6% with placebo 1

Eye Protection

• Implement eye protection for all Bell's palsy patients with impaired eye closure 1, 2
• Eye protection strategies include taping, eye ointment, artificial tears, and humidified eye chambers 1
• This is crucial to prevent corneal damage 3

Antiviral Therapy

• Do NOT prescribe oral antiviral therapy alone for Bell's palsy 1, 2
• May consider combination therapy with oral antivirals plus steroids within 72 hours of symptom onset 2, 4
• If using combination therapy, recommended antivirals include valacyclovir (1 g three times daily for 7 days) or acyclovir (400 mg five times daily for 10 days) 4, 5

Follow-up and Referral

• Reassess or refer to a facial nerve specialist if: 1
  1. New or worsening neurologic findings develop at any point
  2. Ocular symptoms develop at any point
  3. Incomplete facial recovery persists 3 months after initial symptom onset

Special Populations

• Children have better prognosis with higher rates of spontaneous recovery (up to 90%) 3, 4
• Pregnant women also have higher spontaneous recovery rates (up to 90%) 4
• The benefit of corticosteroid treatment in children is less conclusive 3

Additional Considerations

• Electrodiagnostic testing may be offered to patients with complete facial paralysis but is NOT recommended for incomplete facial paralysis 1, 3
• MRI with and without contrast is the imaging test of choice when indicated (atypical presentations or no recovery after 3 months) 1, 3
• No recommendation can be made regarding physical therapy due to limited evidence 1, 3
• No recommendation can be made regarding acupuncture due to poor-quality trials 3

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness 2
• Using antiviral therapy alone is ineffective 2, 4
• Failing to provide adequate eye protection for patients with impaired eye closure 2
• Failing to refer patients with incomplete recovery after 3 months 1, 3