Treatment 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
First-Line Treatment
- Prescribe prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
- Start treatment within 72 hours of symptom onset for maximum effectiveness 1, 3
- Evidence shows 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, 4
- Antiviral therapy alone should NOT be prescribed for Bell's palsy 1, 2
Eye Protection
- Implement eye protection for all patients with impaired eye closure to prevent corneal damage 1, 2
- Use lubricating ophthalmic drops frequently throughout the day 1
- Apply ophthalmic ointments for more effective moisture retention, particularly at night 1
- Consider moisture chambers using polyethylene covers for nighttime protection 1
- Use eye patching or taping with caution, particularly at night 1
- Recommend sunglasses for outdoor protection 1
Combination Therapy
- May offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset 1, 2
- Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2
- Benefit of combination therapy is small but risks are minimal 1
- When using antivirals, options include valacyclovir (1 g three times daily for seven days) or acyclovir (400 mg five times daily for 10 days) 5
Special Populations
- Children have better prognosis with higher rates of spontaneous recovery (up to 90%) 1, 5
- Evidence for steroid use in children is less conclusive 1
- Pregnant women should be treated with oral corticosteroids within 72 hours of symptom onset, with careful individualized assessment of benefits and risks 1
Follow-up and Monitoring
- 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
Recovery Timeline
- Approximately 70% of patients with complete paralysis recover facial function completely within 6 months 1, 6
- 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
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours reduces effectiveness of therapy 1, 3
- Using antiviral therapy alone is ineffective 1, 2, 5
- Failing to provide adequate eye protection for patients with impaired eye closure 1
- Not referring patients with incomplete recovery after 3 months for specialist evaluation 1, 7
- Routine laboratory testing and imaging are not required for typical presentations of Bell's palsy 1, 2
When to Consider Additional Testing or Referral
- MRI with and without contrast is the imaging test of choice when indicated, such as for atypical presentations or no sign of recovery after 3 months 1
- Features atypical of Bell's palsy requiring imaging include: second paralysis on same side, isolated branch paralysis, other cranial nerve involvement, or no recovery after 3 months 1
- For severe eye impairment, immediate ophthalmology referral is necessary 1