How to manage an adult with Bell's (Idiopathic Facial) Palsy?

From the Guidelines

Management of an adult with Bell's palsy should begin with early corticosteroid therapy, ideally within 72 hours of symptom onset, as it has been shown to significantly improve outcomes, with 83% of patients recovering facial nerve function 3 months after treatment compared to 63.6% with placebo 1.

Key Recommendations

• Prescribe prednisone 60-80 mg daily or prednisolone 50-60 mg daily for 7-10 days, then taper over the next 3-5 days, as supported by high-quality randomized controlled trials 1.
• Antiviral therapy with valacyclovir 1000 mg three times daily or acyclovir 400 mg five times daily for 7 days may be added, particularly in cases with severe paralysis, though evidence for its benefit is less robust than for steroids 1.
• Eye protection is crucial, advise artificial tears during the day (every 2-4 hours), lubricating ointment at night, and eye taping if complete closure is not possible, as recommended by clinical practice guidelines 1.

Additional Considerations

• Physical therapy with facial exercises and massage can help maintain muscle tone, although the evidence for its effectiveness is not as strong as for corticosteroids 1.
• Patients should be reassured that approximately 70-85% will recover completely within 3-6 months without treatment, though steroids improve these outcomes 1.
• If no improvement occurs within 3 months or if symptoms worsen after initial improvement, refer for neurological evaluation to rule out other causes, as recommended by clinical practice guidelines 1.
• Monitor for complications such as corneal abrasions, synkinesis (unwanted facial movements), or contractures, and provide psychological support as facial paralysis can cause significant emotional distress 1.

From the Research

Diagnosis of Bell's Palsy

• Bell's palsy should be suspected in patients with acute onset of unilateral facial weakness or paralysis involving the forehead in the absence of other neurologic abnormalities 2.
• Laboratory testing and imaging are not required for diagnosis, but may be used to identify a treatable cause when other causes of facial weakness are being considered 2.

Treatment of Bell's Palsy

• An oral corticosteroid regimen (prednisone, 50 to 60 mg per day for five days followed by a five-day taper) is the first-line treatment for Bell's palsy 2.
• Combination therapy with an oral corticosteroid and antiviral may reduce rates of synkinesis (misdirected regrowth of facial nerve fibers manifesting as involuntary co-contraction of certain facial muscles) 2, 3.
• Recommended antivirals include valacyclovir (1 g three times per day for seven days) or acyclovir (400 mg five times per day for 10 days) 2.
• Treatment with antivirals alone is ineffective and not recommended 2.
• Physical therapy may be beneficial in patients with more severe paralysis 2.
• High-dose corticosteroids (initial prednisolone of 100 mg or more daily) may be associated with a significantly decreased nonrecovery at 6 months after disease onset compared to standard-dose corticosteroids 4.

Prognosis and Recovery

• The overall prognosis for Bell's palsy is good, with more than two-thirds of patients having a complete spontaneous recovery 2.
• For children and pregnant women, the rate of complete recovery is up to 90% 2.
• The rate of complete recovery can be improved with treatment, particularly with corticosteroids 5, 6.
• The addition of an antiviral to steroids may increase the likelihood of recovery, but only by a very modest effect 6.