What are the treatment options for Bell's palsy?

Treatment Options for Bell's Palsy

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

First-Line Treatment

• Recommended corticosteroid regimens include 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
• Treatment should be initiated within 72 hours of symptom onset for maximum effectiveness 1, 3

Combination Therapy Options

• Oral antiviral therapy may be offered in addition to oral steroids within 72 hours of symptom onset 1
• Recommended antivirals include valacyclovir (1 g three times per day for seven days) or acyclovir (400 mg five times per day for 10 days) 2
• Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 1
• Combination therapy may reduce rates of synkinesis (misdirected regrowth of facial nerve fibers) 2
• Antiviral therapy alone is ineffective and not recommended 1, 2

Eye Protection Measures

• Eye protection is essential for all patients with impaired eye closure to prevent corneal damage 1
• Primary eye protection methods include:
  • Lubricating ophthalmic drops used frequently throughout the day 1
  • Ophthalmic ointments for more effective moisture retention, particularly at night 1
  • Moisture chambers using polyethylene covers for nighttime protection 1
  • Eye patching or taping with proper technique instruction 1
  • Sunglasses for outdoor protection 1
• For severe impairment, immediate ophthalmology referral is necessary 1

Additional Treatment Options

• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited 3, 2
• For patients with incomplete facial recovery after 3 months:
  • Botulinum toxin injections can provide temporary improvement for months 1, 4
  • Surgical options may include tarsorrhaphy (temporary or permanent surgical closure of part of the eyelid) 1
  • Eyelid weight implantation can improve closure 1
  • Various reconstructive procedures are available including brow lifts and facial slings 5

Special Populations

• Children have better prognosis with higher rates of spontaneous recovery (up to 90%) 1, 2
• 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

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

Prognosis

• Approximately 70% of 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
• Approximately 30% of patients may experience permanent facial weakness with muscle contractures 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness of therapy 1
• Using antiviral therapy alone is ineffective 1, 2
• Improper eye taping technique can cause corneal abrasion 1
• Relying solely on eye drops without nighttime protection can lead to exposure keratitis 1
• Delaying specialist referral for patients with severe or persistent symptoms can result in permanent corneal damage 1