What is the immediate treatment for a patient with Bell's palsy?

Immediate Treatment for Bell's Palsy

Start oral corticosteroids immediately within 72 hours of symptom onset—this is the single most important intervention that significantly improves facial nerve recovery. 1

First-Line Treatment Protocol

Prescribe one of these corticosteroid regimens: 1, 2

• Prednisolone 50 mg daily for 10 days, OR
• Prednisone 60 mg daily for 5 days, then taper by 10 mg daily over the next 5 days 1, 2

The evidence is compelling: 83% of patients recover at 3 months with prednisolone versus only 63.6% with placebo, and 94.4% recover at 9 months versus 81.6% with placebo. 2 This represents a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery for all patients 16 years and older. 1, 2

Combination Therapy Decision

Consider adding antiviral therapy to corticosteroids for patients with severe paralysis or those presenting early (within 72 hours). 1, 3

If adding antivirals: 4

• Valacyclovir 1 g three times daily for 7 days, OR
• Acyclovir 400 mg five times daily for 10 days 4

One study demonstrated 96.5% complete recovery with combination therapy versus 89.7% with steroids alone. 1 However, never prescribe antivirals as monotherapy—this is ineffective and explicitly not recommended. 1, 2

Critical Eye Protection (Implement Immediately)

For any patient with impaired eye closure, start aggressive eye protection immediately to prevent corneal damage: 1, 2

• Lubricating ophthalmic drops frequently throughout the day 2
• Ophthalmic ointment at bedtime (more effective moisture retention but causes temporary vision blurring) 2
• Eye patching or taping at night (requires careful instruction on proper technique to avoid corneal abrasion) 2
• Sunglasses for outdoor protection 2
• Moisture chambers using polyethylene covers for nighttime 2

Refer immediately to ophthalmology if severe lagophthalmos is present. 2

Essential Diagnostic Exclusions

Before diagnosing Bell's palsy, confirm: 2

• Acute onset within 72 hours 2
• Unilateral facial weakness involving the forehead (distinguishes from central causes) 2, 4
• No other cranial nerve involvement 2
• No bilateral weakness (suggests alternative diagnosis) 2

Do NOT order routine laboratory tests or imaging for typical presentations—diagnosis is clinical. 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours dramatically reduces effectiveness 1, 3
• Using antiviral monotherapy is completely ineffective 1, 2
• Failing to provide adequate eye protection can lead to permanent corneal damage 1, 2
• Missing atypical features that require imaging (second paralysis on same side, isolated branch paralysis, other cranial nerve involvement) 2

Follow-Up Requirements

Reassess or refer to a facial nerve specialist if: 1, 2

• New or worsening neurologic findings develop at any point 1, 2
• Ocular symptoms develop 1, 2
• Incomplete facial recovery persists at 3 months after symptom onset 1, 2

Special Population Considerations

Children: Have better prognosis with up to 90% spontaneous recovery, but evidence for steroid benefit is less conclusive—consider treatment on individualized basis with caregiver involvement. 2, 4

Pregnant women: Treat with oral corticosteroids using careful individualized risk-benefit assessment. 2

Elderly patients (>60 years): May benefit more from combination therapy—one study showed 100% complete recovery in treated elderly patients versus 42% in untreated controls. 5