What is the treatment approach for recurrent Bell's palsy?

Treatment Approach for Recurrent Bell's Palsy

The 2013 AAO-HNS clinical practice guideline explicitly states it does not address recurrent facial paresis/paralysis, leaving no evidence-based protocol for recurrent Bell's palsy. 1

Critical Diagnostic Imperative

Recurrent facial paralysis on the same side is an atypical feature that mandates imaging and specialist referral to exclude other pathologies. 2

• MRI with and without contrast is the imaging test of choice when evaluating recurrent episodes, as second paralysis on the same side suggests an alternative diagnosis such as tumor, infection, or systemic disease 2
• Bilateral Bell's palsy is rare, and recurrence raises concern for conditions like sarcoidosis, Lyme disease, or neoplasm 1
• Refer to a facial nerve specialist or neurologist immediately for comprehensive evaluation 1

Treatment During Acute Recurrent Episode

If other causes are excluded and true recurrent Bell's palsy is confirmed, treat the acute episode identically to first-time Bell's palsy with oral corticosteroids within 72 hours of symptom onset. 2, 3

Corticosteroid Regimen

• Prescribe prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 2, 3
• This must be initiated within 72 hours of symptom onset to be effective 3, 4
• Evidence shows 83% recovery at 3 months with prednisolone versus 63.6% with placebo in first-time Bell's palsy 2

Combination Therapy Consideration

• May offer oral antiviral therapy (valacyclovir 1 g three times daily for 7 days or acyclovir 400 mg five times daily for 10 days) in addition to corticosteroids within 72 hours 5, 6
• Some evidence suggests combination therapy may reduce synkinesis rates and improve complete recovery (96.5% versus 89.7% with steroids alone) 3, 5
• Never prescribe antiviral monotherapy as it is ineffective 2, 3

Mandatory Eye Protection

Implement aggressive eye protection immediately for any patient with impaired eye closure to prevent corneal damage. 2, 3

• Use lubricating ophthalmic drops frequently throughout the day 2
• Apply ophthalmic ointments at night for moisture retention 2
• Employ eye patching or taping with careful instruction on proper technique to avoid corneal abrasion 2
• Use sunglasses for outdoor protection 2
• Refer to ophthalmology immediately if severe impairment, eye pain, vision changes, or increasing irritation occurs 2

Follow-Up Algorithm

Reassess at 3 months after symptom onset; incomplete recovery mandates specialist referral. 2, 3

• Monitor for new or worsening neurologic findings at any point, which requires immediate specialist referral 2, 3
• Watch for ocular symptoms developing, which requires immediate specialist referral 2, 3
• If incomplete facial recovery persists at 3 months, refer to facial nerve specialist for consideration of reconstructive procedures 1, 2

Common Pitfalls in Recurrent Cases

• Failing to image recurrent episodes: This is the most critical error, as recurrence strongly suggests alternative pathology requiring different management 2
• Assuming recurrence is benign: Recurrent facial paralysis on the same side is atypical and warrants thorough investigation 2
• Delaying treatment beyond 72 hours: Corticosteroid efficacy drops significantly after this window 3, 4
• Inadequate eye protection: This can lead to permanent corneal damage and vision loss 2, 3
• Not referring for specialist evaluation: Recurrent cases require expert assessment to exclude systemic disease 1, 2

Prognosis Considerations

• Approximately 70% of patients with complete paralysis recover fully within 6 months, and up to 94% with incomplete paralysis recover 2, 4
• Recurrence rate in general Bell's palsy population is 12% 7
• Recovery typically begins within 2-3 weeks, with complete recovery by 3-4 months in most cases 2
• 30% may experience permanent facial weakness with muscle contractures 2