What is the treatment for Bell's palsy?

Treatment of Bell's Palsy

Immediate Medical Management

Prescribe oral corticosteroids within 72 hours of symptom onset for all Bell's palsy patients 16 years and older—this is the only evidence-based treatment that significantly improves facial nerve recovery. 1

Corticosteroid Regimen

• Prednisolone 50 mg daily for 10 days OR Prednisone 60 mg daily for 5 days followed by a 5-day taper 1
• Strong evidence demonstrates 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 1
• Treatment effectiveness drops significantly if initiated beyond the 72-hour window 1

Antiviral Therapy Considerations

• Antiviral monotherapy alone is ineffective and should NOT be prescribed 1
• Combination therapy (oral steroids PLUS antivirals) may be offered as an option within 72 hours, showing marginally higher complete recovery rates (96.5% versus 89.7% with steroids alone), though the benefit is small 1
• If prescribing antivirals, use valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 2

Essential Eye Protection Protocol

All patients with impaired eye closure require immediate aggressive eye protection to prevent permanent corneal damage. 1

Daytime Protection

• Apply lubricating ophthalmic drops frequently throughout the day (does not blur vision but requires repeated application) 1
• Use sunglasses outdoors for protection against foreign particles and irritants 1

Nighttime Protection

• Apply ophthalmic ointments at bedtime for superior moisture retention (may cause temporary vision blurring) 1
• Consider moisture chambers using polyethylene covers for enhanced nighttime protection 1
• Use eye patching or taping with careful instruction on proper technique to avoid corneal abrasion 1

Urgent Ophthalmology Referral Triggers

• Severe impairment with incomplete eye closure requires immediate ophthalmology evaluation 1
• Eye pain, vision changes, redness, discharge, foreign body sensation, or increasing irritation despite protection measures 1

Diagnosis Confirmation

Bell's palsy is diagnosed clinically by acute unilateral facial weakness or paralysis with forehead involvement, developing over less than 72 hours, without identifiable cause 1

Key Diagnostic Features

• Rapid onset of unilateral facial weakness affecting the forehead (distinguishes from central causes) 1
• May include ipsilateral ear pain, hyperacusis, taste disturbance on anterior two-thirds of tongue, and dry eye/mouth 1
• Systematically assess all facial movements: raising eyebrows, closing eyes tightly, smiling, puffing cheeks 1

When NOT to Diagnose Bell's Palsy

• Do NOT order routine laboratory testing or imaging for typical Bell's palsy 1
• Atypical features requiring MRI with and without contrast include: recurrent paralysis on same side, isolated branch paralysis, other cranial nerve involvement, bilateral facial weakness, or no recovery after 3 months 1, 3

Follow-Up Algorithm

2-3 Week Assessment

• Most patients begin showing signs of recovery within 2-3 weeks 1
• Continue eye protection measures as needed 1

3-Month Mandatory Reassessment

Patients with incomplete facial recovery at 3 months MUST be reassessed or referred to a facial nerve specialist 1

Immediate Referral Triggers (Any Time Point)

• New or worsening neurologic findings 1
• Development of ocular symptoms 1
• Persistent lagophthalmos requiring consideration of tarsorrhaphy or eyelid weight implantation 1

Special Populations

Children

• Better prognosis with higher spontaneous recovery rates (up to 90%) 2
• Evidence for corticosteroid benefit in children is less conclusive 1
• Consider oral steroids on an individualized basis with caregiver involvement 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using the same regimen as non-pregnant patients 1
• Combination therapy with antivirals may be considered 1
• Eye protection is essential 1

Prognosis

• Approximately 70% of patients with complete paralysis recover fully within 6 months 1
• Up to 94% with incomplete paralysis recover completely 1
• Complete recovery typically occurs within 3-4 months for most patients 1
• 30% may experience permanent facial weakness with muscle contractures 1

Interventions NOT Recommended

Physical Therapy

• No evidence supports benefit or harm of physical therapy for Bell's palsy 4
• A Cochrane systematic review found no treatment produced significantly more improvement than untreated control groups 4
• May be considered for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited 5, 2

Acupuncture

• No recommendation can be made regarding acupuncture due to poor-quality trials and indeterminate benefit-to-harm ratio 1

Long-Term Management for Incomplete Recovery

Reconstructive Options (After 3 Months)

• Eyelid weights for persistent incomplete eye closure 1
• Brow lifts and static facial slings for functional improvement 1
• Dynamic facial slings and nerve transfers for more complex cases 1
• Facial muscles remain viable re-innervation targets for up to 2 years 6

Psychological Support

• Patients with persistent facial paralysis experience significant psychosocial dysfunction and diminished quality of life 1
• Depression screening and referral to appropriate specialist as needed 1
• Difficulty expressing emotion impairs social interaction and may lead to stigmatization 1

Critical Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours reduces effectiveness 1
• Prescribing antiviral therapy alone is ineffective 1
• Inadequate eye protection can lead to permanent corneal damage 1
• Failing to refer at 3 months delays access to reconstructive options 1
• Missing atypical features (recurrent paralysis, bilateral involvement, isolated branch paralysis) that require imaging and specialist evaluation 1, 3
• Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction 1