From the Guidelines
Oral corticosteroids should be prescribed within 72 hours of symptom onset for Bell’s palsy patients 16 years and older. This recommendation is based on high-quality randomized controlled trials, such as the study by Sullivan et al 1, which reported significant improvement of facial nerve function in patients treated with prednisolone within 72 hours of onset. The study found that 83% of participants randomized to prednisolone had recovered facial nerve function 3 months after treatment compared with 63.6% of those randomized to placebo.
Key Considerations
- The treatment should start with oral corticosteroids like prednisone, with a dose of 60-80mg daily for 7 days, then tapered over the next 7 days.
- Antiviral medications such as valacyclovir may be added, especially if herpes virus infection is suspected, though evidence for their benefit is less robust than for steroids 1.
- Eye protection is crucial for patients who cannot close their affected eye completely, including artificial tears during the day, lubricating ointment at night, and possibly taping the eye shut or using an eye patch to prevent corneal damage.
- Physical therapy, including facial exercises and massage, may help maintain muscle tone and stimulate nerve function.
Supporting Evidence
The study by Engstrom et al, a randomized, double-blind, placebo-controlled, multicenter trial involving 829 patients, compared the short- and long-term effects of prednisolone and valacyclovir in facial nerve recovery attributed to Bell’s palsy 1. The results showed statistically significant shorter times to recovery in patients treated with prednisolone compared with those who did not receive prednisolone.
Clinical Implications
Most patients recover completely within 3-6 months without treatment, but early corticosteroid therapy increases the likelihood of full recovery and reduces the risk of long-term facial weakness. Prompt treatment addresses the inflammation of the seventh cranial nerve, which controls facial muscles, to protect the nerve from permanent damage. The clinical practice guideline by the American Academy of Otolaryngology-Head and Neck Surgery also supports the use of oral steroids within 72 hours of symptom onset for Bell’s palsy patients 16 years and older 1.
From the Research
Treatment Options for Bell's Palsy
- The mainstay of treatment for Bell's palsy is corticosteroids, which should be initiated within 72 hours of symptom onset 2, 3, 4.
- Antiviral therapy in combination with corticosteroid therapy may confer a small benefit and may be offered on the basis of shared decision making 2, 5.
- The use of high-dose corticosteroids (initial prednisolone of 100mg or more daily) may be associated with a significantly decreased nonrecovery at 6 months after disease onset compared to standard-dose corticosteroids 6.
Timing of Treatment
- Initiating treatment within 72 hours of symptom onset is crucial for optimal recovery 2, 3, 4.
- However, one study suggested that initiating treatment beyond 72 hours may be associated with a higher recovery rate than starting treatment within 72 hours, although this should be interpreted with caution due to the limitations of retrospective analysis 4.
Factors Affecting Recovery
- Age: patients aged 20 to 39 years had a higher recovery rate than other age groups 4.
- Electroneurography (ENoG) and electromyography (EMG) results: fairly predictive EMG results were associated with significantly higher recovery rates 4.
- Comorbid conditions: the presence of comorbid conditions may affect recovery rates, although the specific impact is unclear 4.
Other Treatment Modalities
- Acupuncture, physical therapy, electrotherapy, and surgical decompression are not recommended due to a lack of well-designed studies and low-quality available data 2.