What is the management of 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 only proven medical therapy 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 2, 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
• Treatment beyond 72 hours has no proven benefit and should not be initiated 1

Antiviral Therapy Considerations

• Antiviral monotherapy is ineffective and should NOT be prescribed 2, 1
• Combination therapy (oral steroids PLUS antivirals) may be offered as an optional addition within 72 hours, though the benefit is small 1
• If choosing combination therapy, use valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 3
• Some evidence suggests combination therapy may reduce synkinesis rates (96.5% complete recovery versus 89.7% with steroids alone), but this remains uncertain 1, 3

Eye Protection (Critical for All Patients)

Implement aggressive eye protection immediately for any patient with impaired eye closure—this prevents potentially permanent corneal damage. 1

Daytime Protection

• Apply lubricating ophthalmic drops frequently throughout the day (every 1-2 hours while awake) 4, 1
• Use sunglasses outdoors to protect against foreign particles and wind 4, 1

Nighttime Protection

• Apply ophthalmic ointment at bedtime for sustained moisture retention 4, 1
• Use eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 4, 1
• Consider moisture chambers using polyethylene covers for severe cases 4

Urgent Ophthalmology Referral Indications

• Severe impairment with complete inability to close the eye 4
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Any signs of corneal exposure or damage 4, 1

Initial Diagnostic Assessment

History and Physical Examination

• Confirm acute onset (less than 72 hours) of unilateral facial weakness involving the forehead 1
• Exclude identifiable causes through thorough history: trauma, infection (Lyme disease, herpes zoster), tumor, stroke 4, 1
• Assess severity using House-Brackmann grading system (Grade 1 = normal to Grade 6 = total paralysis) 1
• Test all facial movements: eyebrow elevation, eye closure, smile, cheek puffing 1
• Examine for associated symptoms: periauricular pain, hyperacusis, taste disturbance on anterior two-thirds of tongue 1

Diagnostic Testing

• Routine laboratory testing and imaging are NOT recommended for typical Bell's palsy 1
• Electrodiagnostic testing may be offered only for patients with complete facial paralysis, NOT for incomplete paralysis 1

Atypical Features Requiring Imaging (MRI with and without contrast)

• Recurrent paralysis on the same side 1, 5
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Bilateral facial weakness 1
• No recovery after 3 months 1

Follow-Up and Reassessment

Mandatory Reassessment or Specialist Referral Triggers

• Incomplete facial recovery at 3 months after symptom onset 4, 1
• New or worsening neurologic findings at any point 4, 1
• Development of ocular symptoms at any point 4, 1

Expected Recovery Timeline

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

Special Populations

Children

• Children have better prognosis with higher spontaneous recovery rates (up to 90%) than adults 1, 3
• Evidence for corticosteroid benefit in children is inconclusive 1
• Treatment decisions should involve substantial caregiver participation in shared decision-making 1
• If treating, use 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 individualized risk-benefit assessment 1
• Use same dosing regimen as non-pregnant adults 1
• Eye protection is essential and follows same protocols 1

Recurrent Bell's Palsy

• Recurrence on the same side is atypical and mandates immediate imaging and specialist referral to exclude tumor, infection, or systemic disease 5
• Treat the acute episode identically to first-time Bell's palsy with corticosteroids within 72 hours 5
• Consider alternative diagnoses: sarcoidosis, Lyme disease, neoplasm 5

Long-Term Management (Beyond 3 Months)

Reconstructive Options for Incomplete Recovery

• Refer to facial nerve specialist or facial plastic surgeon for evaluation 4, 1
• Static procedures: eyelid weights, brow lifts, static facial slings 4, 1
• Dynamic procedures: dynamic facial slings, nerve transfers 1
• Tarsorrhaphy (partial eyelid closure) for persistent severe lagophthalmos 1

Psychological Support

• Patients with persistent paralysis experience significant psychosocial dysfunction and diminished quality of life 4, 1
• Difficulty expressing emotion impairs social interaction 4
• Screen for depression and refer to appropriate specialist when needed 4
• Consider counseling or support groups 4

Therapies NOT Recommended

• Physical therapy: No recommendation can be made due to limited evidence (only case series available) 1
• Acupuncture: No recommendation can be made due to poor-quality trials 1
• Surgical decompression: Rarely indicated and requires comparison with medical management in specialized centers 4

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates proven benefit 2, 1
• Prescribing antiviral monotherapy, which is completely ineffective 2, 1
• Inadequate eye protection leading to corneal damage in patients with lagophthalmos 4, 1
• Failing to refer patients with incomplete recovery at 3 months, delaying access to reconstructive options 4, 1
• Missing atypical features that require imaging and specialist evaluation 1, 5
• Improper eye taping technique causing corneal abrasion—patients must receive careful instruction 1