What constitutes a complete Bell's palsy examination and treatment?

Complete Bell's Palsy Examination and Treatment

A thorough Bell's palsy examination requires a comprehensive history and physical examination to exclude other causes of facial weakness, followed by prompt treatment with oral steroids within 72 hours of symptom onset for patients 16 years and older. 1

Diagnostic Assessment

History

• Document timing of symptom onset (Bell's palsy develops rapidly over 24-72 hours) 1, 2
• Inquire about:
  • Viral prodrome or recent infections 1
  • Pain around ear or face 2
  • Hyperacusis (increased sensitivity to sound) 2
  • Taste disturbance on anterior two-thirds of tongue 2
  • Dizziness, dysphagia, or diplopia (suggests alternative diagnosis) 1
  • Underlying medical conditions (diabetes, hypertension, pregnancy) 3
  • Prior history of facial paralysis, stroke, head/facial trauma 1
  • Skin cancers, parotid tumors, or cerebellopontine angle pathology 1

Physical Examination

• Assess facial weakness pattern:
  • Test forehead involvement (crucial to distinguish from central causes) 2
  • Evaluate eye closure, smile, and ability to puff cheeks 2
  • Grade severity using House-Brackmann scale (grades 1-6) 2
• Document function of all cranial nerves 1
• Evaluate eye for signs of exposure (critical for management) 1, 2
• Assess for Bell's phenomenon (upward eye movement during attempted lid closure) 2
• Examine ears, parotid gland, and skin for lesions 1

Diagnostic Testing

• Do not obtain routine laboratory testing for typical presentations 1
• Do not routinely perform diagnostic imaging for new-onset Bell's palsy 1
• Consider targeted testing only when history suggests alternative diagnoses:
  • Lyme disease serology in endemic areas 1
  • Diabetes screening if risk factors present 4
• Electrodiagnostic testing:
  • Not recommended for incomplete facial paralysis 1
  • May be offered for complete facial paralysis 1
• Consider MRI with and without contrast only for:
  • Atypical presentations
  • No recovery after 3 months
  • Worsening symptoms 2

Treatment Protocol

First-Line Treatment

• Prescribe oral steroids 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 5-day taper 2, 5
• Evidence shows significant improvement with steroids:
  • 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 2

Antiviral Therapy

• Do not prescribe oral antiviral therapy alone 1
• May offer antiviral therapy in addition to oral steroids within 72 hours of symptom onset 1
• Options if adding antivirals:
  • Valacyclovir 1g three times daily for 7 days OR
  • Acyclovir 400mg five times daily for 10 days 5

Eye Protection (Critical)

• Implement eye protection for all patients with impaired eye closure 1, 2
• Recommended measures:
  • Frequent lubricating ophthalmic drops during the day 2
  • Ophthalmic ointments at night 2
  • Moisture chambers using polyethylene covers for nighttime 2
  • Eye taping or patching (with proper technique) 2
  • Sunglasses for outdoor protection 2
• For severe impairment, consider urgent ophthalmology referral 2

Follow-up and Referral

• Reassess or refer to facial nerve specialist for patients with:
  • New or worsening neurologic findings at any point
  • Ocular symptoms developing at any point
  • Incomplete facial recovery 3 months after initial symptom onset 1
• Most patients begin showing signs of recovery within 2-3 weeks 2
• Complete recovery typically occurs within 3-4 months for most patients 2

Prognosis and Complications

• Approximately 70-80% of patients recover spontaneously 4
• Recovery rates are higher with:
  • Incomplete facial paralysis (up to 94%) 2
  • Treatment with steroids within 72 hours 2
  • Younger age 2
• Potential complications:
  • Incomplete eyelid closure with resultant dry eye (short-term) 4
  • Permanent facial weakness with muscle contractures (long-term) 4
  • Synkinesis (involuntary co-contraction of facial muscles) 5, 6

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours (reduces effectiveness) 2
• Using antiviral therapy alone (ineffective) 1, 5
• Inadequate eye protection (can lead to corneal damage) 2
• Failing to test forehead function (critical to distinguish from central causes) 2
• Delaying specialist referral for patients with severe or persistent symptoms 2