What is the management of Bell's palsy?

Management of Bell's Palsy

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy, using prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper. 1

Initial Assessment and Diagnosis

Confirm the diagnosis through history and physical examination to exclude other identifiable causes of facial paralysis before initiating treatment. 1

Key diagnostic features to establish:

• Acute onset of unilateral facial weakness developing over less than 72 hours 1
• Involvement of the forehead (distinguishes from central causes) 1
• No other neurologic abnormalities present 2
• Assess severity using House-Brackmann grading system (grades 1-6) 1

Do NOT order routine laboratory testing or diagnostic imaging for typical Bell's palsy presentations. 1

Pharmacologic Treatment

Corticosteroid Therapy (First-Line)

Initiate corticosteroids within 72 hours of symptom onset - this timing is critical for effectiveness. 3, 1

Recommended regimens:

• Prednisolone 50 mg daily for 10 days, OR 1
• Prednisone 60 mg daily for 5 days followed by 5-day taper 1

Evidence supporting this approach:

• 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1

Antiviral Therapy Considerations

Do NOT prescribe antiviral therapy alone - it is ineffective as monotherapy. 3, 1

May offer combination therapy with oral antivirals plus corticosteroids within 72 hours as an optional addition, though benefit is small. 4, 1

If choosing combination therapy:

• Valacyclovir 1 g three times daily for 7 days, OR 2
• Acyclovir 400 mg five times daily for 10 days 2

The evidence shows modest benefit: 96.5% complete recovery with combination therapy versus 89.7% with steroids alone, though this represents a small incremental benefit. 1

Eye Protection (Essential)

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent corneal damage. 3, 1

Daytime Protection

• Apply lubricating ophthalmic drops frequently throughout the day 3, 1
• Wear sunglasses outdoors for protection against foreign particles 3, 1

Nighttime Protection

• Apply ophthalmic ointments at bedtime for sustained moisture retention 3, 1
• Consider moisture chambers using polyethylene covers 3
• Use eye patching or taping with proper technique instruction (improper technique can cause corneal abrasion) 3, 1

Severe Cases Requiring Specialist Referral

For patients with severe lagophthalmos:

• Refer immediately to ophthalmology for evaluation 3
• Consider botulinum toxin injections for temporary improvement 3
• Surgical options include tarsorrhaphy or eyelid weight implantation 3

Seek urgent ophthalmology consultation for eye pain, vision changes, redness, discharge, or foreign body sensation. 3

Follow-Up and Monitoring

Routine Follow-Up Timeline

Reassess patients at 3 months after initial symptom onset to evaluate for incomplete recovery. 3, 1

Most patients show recovery patterns:

• Recovery begins within 2-3 weeks of symptom onset 1, 5
• Complete recovery typically occurs within 3-4 months 1, 5
• 70% of patients with complete paralysis recover fully within 6 months 1
• 94% of patients with incomplete paralysis recover fully 1

Indications for Specialist Referral

Refer to facial nerve specialist or appropriate specialist if:

• New or worsening neurologic findings develop at any point 3, 1
• Ocular symptoms develop at any point 3, 1
• Incomplete facial recovery persists at 3 months after symptom onset 3, 1

Red Flags Requiring Imaging

Order MRI with and without contrast if atypical features present: 1

• Second paralysis on same side 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• No recovery after 3 months 1
• Bilateral facial weakness 1

Special Populations

Children

• Children have better prognosis with up to 90% complete recovery rates 2
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider oral steroids on individualized basis with caregiver involvement 1

Pregnant Women

• Treat pregnant women with oral corticosteroids within 72 hours using careful risk-benefit assessment 1
• Combination therapy with antivirals may be considered 1
• Eye protection remains essential 1

Physical Therapy

Consider physical therapy for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited. 3, 2

Management of Complications

Synkinesis (Abnormal Facial Movements)

• Early identification through regular monitoring improves outcomes 3
• Physical therapy may be beneficial 3
• Refer to facial nerve specialist for persistent cases 3

Persistent Pain Beyond 2 Weeks

• Consider gabapentin 1800-3600 mg/day divided three times daily for neuropathic pain 5
• Do NOT restart or extend corticosteroid therapy beyond initial 10-day course 5
• Continue aggressive eye protection measures 5

Incomplete Recovery at 3 Months

• Approximately 30% may experience permanent facial weakness with muscle contractures 1
• Refer to facial nerve specialist for evaluation of surgical options 1
• Address aesthetic, functional, and psychological considerations through multidisciplinary approach 6

Critical Pitfalls to Avoid

• Delaying treatment beyond 72 hours significantly reduces effectiveness 1, 5
• Using antiviral therapy alone is completely ineffective 3, 1
• Failing to test forehead function leads to misdiagnosis of central causes 1
• Neglecting eye protection even when pain is primary complaint risks corneal damage 5
• Improper eye taping technique can cause corneal abrasion 3
• Restarting corticosteroids after initial treatment window has no evidence support 5