Management of Bell's Palsy
First-Line Treatment: Oral Corticosteroids
All patients 16 years and older with Bell's palsy should receive oral corticosteroids within 72 hours of symptom onset. 1, 2
- Prednisolone 50 mg daily for 10 days, OR
- Prednisone 60 mg daily for 5 days followed by a 5-day taper
Evidence for efficacy is strong: 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 2, 3
Critical timing: Treatment beyond 72 hours significantly reduces effectiveness and should be avoided 1, 2
Antiviral Therapy Considerations
Antiviral monotherapy should NEVER be prescribed for Bell's palsy—it is ineffective. 1, 2
Combination therapy (oral antivirals plus corticosteroids) may be offered within 72 hours as an optional addition to steroids 1, 2
Recommended antiviral regimens if combination therapy is chosen: 4
- Valacyclovir 1 g three times daily for 7 days, OR
- Acyclovir 400 mg five times daily for 10 days
Some evidence suggests higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%), though the benefit is small 1, 2
The landmark trial by Sullivan et al. showed no significant benefit of acyclovir alone or added to prednisolone 3
Eye Protection: Critical for All Patients with Impaired Eye Closure
Implement immediate eye protection measures to prevent corneal damage—this is non-negotiable. 1, 2
Daytime Protection
- Lubricating ophthalmic drops frequently throughout the day (does not blur vision but requires repeated application) 2
- Sunglasses for outdoor protection against foreign particles 2
Nighttime Protection
- Ophthalmic ointments for superior moisture retention (may cause temporary vision blurring) 2
- Eye patching or taping with careful instruction on proper technique to avoid corneal abrasion 2
- Moisture chambers using polyethylene covers are particularly effective 2
Severe Cases Requiring Urgent Ophthalmology Referral
- Immediate referral for patients with severe impairment or incomplete eye closure 5, 2
- Surgical options include botulinum toxin injections, tarsorrhaphy (partial eyelid closure), or eyelid weight implantation 2
Warning Signs Requiring Urgent Care
- Eye pain, vision changes, redness, discharge, foreign body sensation, or increasing irritation despite protection measures 2
Initial Assessment and Diagnosis
Diagnosis requires careful exclusion of other causes through history and physical examination—routine laboratory testing and imaging are NOT recommended for typical presentations. 1, 2
Key Physical Examination Findings
- Acute unilateral facial weakness involving the forehead (distinguishes from central causes) 2
- Onset within 72 hours 2
- Use House-Brackmann grading system (grades 1-6) to assess severity 2
- Associated symptoms may include ipsilateral ear/face pain, hyperacusis, taste disturbance on anterior two-thirds of tongue, dry eye and mouth 2
Red Flags Requiring Imaging (MRI with and without contrast)
- Second paralysis on same side 2
- Isolated branch paralysis 2
- Other cranial nerve involvement 2
- No recovery after 3 months 2
- Bilateral facial weakness (rare in Bell's palsy) 2
Electrodiagnostic Testing
- May be offered to patients with complete facial paralysis 2
- NOT recommended for incomplete facial paralysis 2
Follow-Up and Referral Criteria
Mandatory reassessment or specialist referral is required for: 1, 2
- Incomplete facial recovery at 3 months after symptom onset
- New or worsening neurologic findings at any point
- Development of ocular symptoms at any point
Long-Term Management for Incomplete Recovery
- Refer to facial nerve specialist or facial plastic surgeon for evaluation of reconstructive procedures 2
- Ophthalmology referral for persistent eye closure problems 2
- Psychological support for quality of life issues—patients experience significant psychosocial dysfunction, difficulty expressing emotion, and stigmatization 5, 2
Reconstructive Options
- Static procedures: eyelid weights, brow lifts, static facial slings 5, 2
- Dynamic procedures: dynamic facial slings, nerve transfers 2
- Tarsorrhaphy or eyelid weight implantation for severe persistent lagophthalmos 2
Special Populations
Children
- Higher rates of spontaneous recovery than adults (up to 90%) 4, 2
- Evidence for steroid benefit in children is inconclusive 1, 2
- Treatment decision should involve substantial caregiver participation in shared decision-making 2
- If treating, consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper 2
- Most children recover completely without treatment 2
Pregnant Women
- Should be treated with oral corticosteroids within 72 hours on an individualized basis with careful assessment of benefits and risks 2
- Combination therapy with antivirals may be considered on an individualized basis 2
- Eye protection remains essential 2
Physical Therapy and Acupuncture
- Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis 6, 4
- No recommendation can be made regarding acupuncture due to poor-quality trials 2
- Evidence for specific physical therapy protocols is limited 2, 6
Prognosis and Natural History
- Approximately 70% of patients with complete paralysis recover completely within 6 months 2
- Patients with incomplete paralysis have higher recovery rates (up to 94%) 2
- Most patients begin showing recovery within 2-3 weeks 2
- Complete recovery typically occurs within 3-4 months 2
- 30% may experience permanent facial weakness with muscle contractures 2
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours—this significantly reduces effectiveness 1, 2
- Using antiviral monotherapy—this is completely ineffective 1, 2
- Failing to provide adequate eye protection, leading to corneal damage 1, 2
- Not testing forehead function, missing the distinction from central causes 2
- Improper eye taping technique causing corneal abrasion 2
- Failing to refer at 3 months for incomplete recovery, delaying access to reconstructive options 2
- Ordering routine laboratory tests and imaging for typical presentations 1, 2