What is the recommended management for Bell's (Bell's) palsy?

Management of Bell's Palsy

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

Initial Assessment and Diagnosis

• Bell's palsy is an acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without an identifiable cause, characterized by rapid onset of unilateral facial weakness or paralysis involving the forehead 1
• Diagnosis requires careful elimination of other causes through thorough history and physical examination 1
• Routine laboratory testing and diagnostic imaging are NOT recommended for Bell's palsy diagnosis 1
• Electrodiagnostic testing may be offered to patients with complete facial paralysis, but is not recommended for patients with incomplete facial paralysis 1

Treatment Algorithm

First-Line Treatment

• Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older 1, 2
• Recommended regimens:
  • 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, with 83% recovery at 3 months with prednisolone vs 63.6% with placebo, and 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1, 3

Antiviral Therapy

• Antiviral therapy alone should NOT be prescribed for Bell's palsy 1, 2, 4
• Combination therapy with oral antivirals and corticosteroids may be offered as an option within 72 hours of symptom onset 1, 2
• Some evidence suggests higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2, 5
• However, other studies show no significant benefit of adding antivirals to corticosteroid treatment 3, 6

Eye Protection (Critical)

• Implement eye protection for all patients with impaired eye closure to prevent corneal damage 1, 2
• Eye protection methods include:
  • Frequent lubricating ophthalmic drops throughout the day 1
  • Ophthalmic ointments, particularly at night 1
  • Moisture chambers using polyethylene covers for nighttime protection 1
  • Eye patching or taping (with careful instruction on proper technique) 1
  • Sunglasses for outdoor protection 1

Special Populations

Children

• Children with Bell's palsy have better prognosis than adults, with higher rates of spontaneous recovery 1, 4
• The benefit of corticosteroid treatment in children is inconclusive 1

Pregnant Women

• Pregnant women should be treated with oral corticosteroids within 72 hours of symptom onset, with careful individualized assessment of benefits and risks 1
• Spontaneous recovery rates may be up to 90% in pregnant women 4

Follow-up and Referral

• Patients should be reassessed or referred to a specialist if they have:
  • New or worsening neurologic findings at any point 1, 2
  • Ocular symptoms developing at any point 1, 2
  • Incomplete facial recovery 3 months after initial symptom onset 1, 2
• MRI with and without contrast is the imaging test of choice when indicated (atypical presentations or no sign of recovery after 3 months) 1

Recovery Timeline and Prognosis

• Approximately 70% of Bell's palsy patients with complete paralysis recover facial function completely within 6 months 1
• Patients with incomplete paralysis have higher recovery rates, up to 94% 1
• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 1
• Complete recovery typically occurs within 3-4 months for most patients 1

Management of Complications

Synkinesis

• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis 7, 4, 8
• Early identification and management of synkinesis can improve outcomes and quality of life 7

Persistent Facial Weakness

• Approximately 30% of patients may experience permanent facial weakness with muscle contractures 1
• For longstanding sequelae from incomplete recovery, a multidisciplinary approach addressing aesthetic, functional, and psychological considerations is recommended 8
• Targeted botulinum toxin injection and selective surgical intervention may be considered for long-term disability in facial palsy 8

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness of therapy 2
• Using antiviral therapy alone is ineffective and not recommended 1, 2, 4
• Failing to rule out other causes of facial weakness before diagnosing Bell's palsy 2
• Not providing adequate eye protection for patients with impaired eye closure, which can lead to corneal damage 2
• Improper eye taping technique can cause corneal abrasion 1
• Delaying specialist referral for patients with severe or persistent symptoms can result in permanent corneal damage 1