What is the management of Bell's (Bell's palsy)?

Management of Bell's Palsy

Immediate Treatment (Within 72 Hours of Symptom Onset)

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older—this is the only treatment proven to significantly improve facial nerve recovery. 1, 2

Corticosteroid Regimen

• Prednisolone 50 mg daily for 10 days OR Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• 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 2, 3
• Treatment beyond 72 hours has no proven benefit—do not delay 1, 4

Antiviral Therapy Considerations

• Do NOT prescribe antiviral therapy alone—it is completely ineffective 1, 2, 5
• May offer combination therapy (oral corticosteroid + antiviral) within 72 hours as an option, though the additional benefit is small 2, 5
• If using combination therapy: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 5

Essential Eye Protection (All Patients with Impaired Eye Closure)

Implement aggressive eye protection immediately to prevent corneal damage—this is non-negotiable for any patient who cannot fully close their eye. 1, 2

Daytime Protection

• Lubricating ophthalmic drops every 1-2 hours while awake 2, 4
• Sunglasses outdoors for protection against wind and foreign particles 1, 2

Nighttime Protection

• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2, 4
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Consider moisture chambers using polyethylene covers for severe cases 1, 2

Urgent Ophthalmology Referral Indications

• Complete inability to close the eye 2
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Any signs of corneal exposure or damage 2

Diagnostic Approach

What NOT to Do

• Do NOT order routine laboratory testing or imaging for typical Bell's palsy presentation 2
• Diagnosis is clinical: acute unilateral facial weakness involving the forehead, onset <72 hours, no identifiable cause 2

When to Order MRI

Order MRI with and without contrast if: 2

• Second paralysis on the same side
• Isolated branch paralysis (not complete facial nerve distribution)
• Other cranial nerve involvement
• No recovery after 3 months
• Progressive worsening of symptoms

Electrodiagnostic Testing

• May offer to patients with complete facial paralysis 2
• Do NOT order for patients with incomplete paralysis 2

Follow-Up and Reassessment

Mandatory Reassessment or Specialist Referral at 3 Months

Refer to a facial nerve specialist if incomplete facial recovery persists at 3 months after symptom onset. 1, 2, 4

Immediate Reassessment/Referral Triggers (Any Time Point)

• New or worsening neurologic findings 1, 2, 4
• Development of ocular symptoms 1, 2, 4

Special Populations

Children

• Better prognosis than adults with higher spontaneous recovery rates (up to 90%) 2, 5
• Evidence for corticosteroid benefit in children is inconclusive 1, 2
• May consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis with substantial caregiver involvement in decision-making 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using the same regimen as non-pregnant adults 2
• Combination therapy with antivirals may be considered on an individualized basis 2
• Eye protection is essential and follows the same protocol 2

Physical Therapy

• May be beneficial for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited 1, 4, 5
• No recommendation can be made regarding routine physical therapy due to limited evidence 2

Long-Term Management (Beyond 3 Months)

Reconstructive Options for Incomplete Recovery

• Refer to facial nerve specialist or facial plastic surgeon for evaluation 2, 4
• Static procedures: eyelid weights, brow lifts, static facial slings 2
• Dynamic procedures: dynamic facial slings, nerve transfers 2
• Tarsorrhaphy (temporary or permanent partial eyelid closure) for severe persistent lagophthalmos 2

Psychological Support

• Screen for depression in patients with persistent paralysis 2
• Address psychosocial dysfunction and quality of life issues 2
• Refer to specialist when needed 2

Expected Recovery Timeline

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

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates effectiveness 1, 2
• Prescribing antiviral monotherapy—it is completely ineffective 1, 2, 5
• Inadequate eye protection leading to permanent corneal damage 1, 2
• Failing to refer at 3 months for incomplete recovery 2, 4
• Ordering unnecessary laboratory tests and imaging for typical presentations 2
• Improper eye taping technique causing corneal abrasion 1, 2