What is the recommended management for Bell's palsy?

Management of Bell's Palsy

Immediate Medical Treatment

Start oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older—this is the single most important intervention that significantly improves complete recovery rates from 63.6% to 83% at 3 months and from 81.6% to 94.4% at 9 months. 1, 2

Corticosteroid Regimen

• Prednisolone 50 mg daily for 10 days (preferred regimen) 1
• Alternative: Prednisone 60 mg daily for 5 days followed by a 5-day taper 1
• Do not initiate treatment beyond 72 hours—there is no evidence of benefit after this window 1

Antiviral Therapy Considerations

• Never prescribe antiviral therapy alone—it is completely ineffective 1, 3
• May offer combination therapy (corticosteroid + antiviral) within 72 hours as an option, though the additional benefit is small 1
• If using combination therapy: valacyclovir 1g three times daily for 7 days OR acyclovir 400mg five times daily for 10 days 3
• The landmark 2007 trial showed no benefit of acyclovir alone (71.2% recovery vs 75.7% without acyclovir, p=0.50) 2

Eye Protection (Critical and Non-Negotiable)

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage. 1

Daytime Protection

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

Nighttime Protection

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

Urgent Ophthalmology Referral Needed For:

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

Diagnostic Approach

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

Clinical Diagnosis Requires:

• Acute unilateral facial nerve paresis/paralysis with onset <72 hours 1
• Involvement of the forehead (distinguishes from central causes) 1, 3
• No other identifiable cause after thorough history and physical examination 1

When to Order MRI (with and without contrast):

• Bilateral facial weakness 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Second paralysis on same side 1
• No recovery after 3 months 1
• Atypical presentations 1

Electrodiagnostic Testing:

• May offer to patients with complete facial paralysis 1
• NOT recommended for incomplete facial paralysis 1

Follow-Up and Reassessment

Mandatory Reassessment or Specialist Referral at:

• 3 months if incomplete facial recovery 1
• Any point if new or worsening neurologic findings develop 1
• Any point if ocular symptoms develop 1

Expected Recovery Timeline:

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

Special Populations

Children

• Better prognosis than adults with higher spontaneous recovery rates (up to 90%) 1, 3
• Evidence for corticosteroid benefit is inconclusive in pediatrics 1
• Consider oral corticosteroids on individualized basis with substantial caregiver participation in decision-making 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 individualized risk-benefit assessment 1
• Combination therapy with antivirals may be considered on individualized basis 1
• Eye protection remains essential 1

Long-Term Management for Incomplete Recovery

At 3 Months Without Complete Recovery:

• Refer to facial nerve specialist or facial plastic surgeon for reconstructive evaluation 1
• Ophthalmology referral for persistent eye closure problems 1
• Screen for depression and provide psychological support 1

Reconstructive Options:

• Static procedures: eyelid weights, brow lifts, static facial slings 1
• Dynamic procedures: dynamic facial slings, nerve transfers 1
• Tarsorrhaphy (temporary or permanent partial eyelid closure) for severe persistent lagophthalmos 1
• Botulinum toxin injections for temporary improvement 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates effectiveness 1
• Using antiviral monotherapy—this is completely ineffective 1, 3
• Failing to provide adequate eye protection leads to preventable corneal damage 1
• Not referring at 3 months delays access to reconstructive options 1
• Improper eye taping technique can cause corneal abrasion 1
• Ordering unnecessary laboratory tests and imaging for typical presentations wastes resources 1
• Restarting or extending corticosteroids beyond initial 10-day course has no evidence of benefit 1

Therapies NOT Recommended

• Antiviral monotherapy 1, 3
• Acupuncture (no recommendation can be made due to poor-quality trials) 1
• Physical therapy for routine cases (limited evidence, may consider for severe paralysis with developing synkinesis) 1, 3
• Surgical decompression (rarely indicated except in specialized centers) 1
• Routine laboratory testing or imaging 1