What is the management for Bell's palsy?

Management of Bell's Palsy

Immediate Treatment (Within 72 Hours)

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older—this is the single most effective intervention to improve facial nerve recovery. 1

• Recommended regimen: Prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1
• 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
• Do NOT prescribe antiviral monotherapy—it is ineffective 1, 2
• Optional: Consider adding oral antiviral therapy (valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days) to corticosteroids, as combination therapy may reduce long-term sequelae like synkinesis (RR 0.56,95% CI 0.36-0.87) 1, 2, 3

Essential Eye Protection

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent corneal damage—this is non-negotiable. 1

• Daytime: Apply lubricating ophthalmic drops frequently throughout the day 1
• Nighttime: Use ophthalmic ointments for superior moisture retention (though they cause temporary vision blurring) 1
• Mechanical protection: Eye patching or taping at night (with careful instruction on proper technique to avoid corneal abrasion) 1
• Outdoor protection: Sunglasses to prevent foreign particle exposure 1
• Severe cases: Refer immediately to ophthalmology for consideration of moisture chambers, botulinum toxin injections, tarsorrhaphy, or eyelid weight implantation 1

Diagnostic Approach

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

• Diagnosis requires thorough history and physical examination to exclude identifiable causes of facial paresis/paralysis 1
• Look for: acute onset (<72 hours), unilateral facial weakness involving the forehead, inability to close eyelid, oral incompetence 1
• Red flags requiring MRI with and without contrast: Second paralysis on same side, isolated branch paralysis, other cranial nerve involvement, bilateral facial weakness, or no recovery after 3 months 1, 4
• Electrodiagnostic testing may be offered only to patients with complete facial paralysis, but NOT for incomplete paralysis 1

Follow-Up Algorithm

Mandatory reassessment or specialist referral at 3 months if incomplete facial recovery persists. 1

• Immediate referral triggers at any time point: New or worsening neurologic findings, development of ocular symptoms 1
• At 3 months: If incomplete recovery, refer to facial nerve specialist for evaluation of reconstructive procedures (static procedures like eyelid weights/brow lifts, or dynamic procedures like nerve transfers) 1
• Ophthalmology referral: For persistent lagophthalmos to prevent permanent corneal damage 1
• Psychology referral: For depression or significant psychosocial dysfunction from facial disfigurement 1

Special Populations

Children

• Children have better prognosis with up to 90% complete recovery rates 2
• Corticosteroid benefit in children is inconclusive—involve caregivers in shared decision-making about whether to treat 1
• If treating: Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using the same regimen as non-pregnant adults 1
• Eye protection is critical—use frequent lubricating drops, ointments at night, and mechanical protection 1
• Combination therapy with antivirals may be considered on an individualized basis 1

Recurrent Bell's Palsy

• Recurrence on the same side is atypical and mandates immediate imaging (MRI with contrast) and specialist referral to exclude tumor, sarcoidosis, Lyme disease, or neoplasm 4
• Treat the acute episode identically to first-time Bell's palsy with corticosteroids within 72 hours 4

Prognosis

• Approximately 70% of patients with complete paralysis recover fully within 6 months 1
• Up to 94% with incomplete paralysis recover completely 1
• Most patients begin recovery within 2-3 weeks, with complete recovery by 3-4 months 1
• 30% may experience permanent facial weakness with muscle contractures 1

Critical Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates therapeutic benefit 1, 5
• Using antiviral monotherapy is completely ineffective 1, 2
• Inadequate eye protection leads to permanent corneal damage—this is the most preventable complication 1
• Failing to refer at 3 months delays access to reconstructive options that can significantly improve quality of life 1
• Improper eye taping technique causes corneal abrasion—patients must receive careful instruction 1
• Missing red flags (bilateral weakness, recurrence, other cranial nerve involvement) leads to delayed diagnosis of serious underlying pathology 1, 4