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 treatment that significantly improves facial nerve recovery. 1, 2

Recommended Corticosteroid Regimens

• Prednisolone 50 mg daily for 10 days OR 1, 2
• Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2

The evidence is robust: 83% of patients recover at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recover at 9 months versus 81.6% with placebo. 3, 2

Antiviral Therapy Considerations

Do NOT prescribe antiviral monotherapy—it is ineffective and not recommended. 1, 4

However, you may consider adding oral antiviral therapy to corticosteroids within 72 hours as combination therapy: 1, 2

• Valacyclovir 1 g three times daily for 7 days OR 4
• Acyclovir 400 mg five times daily for 10 days 4

While the largest trial showed no additional benefit from combination therapy 3, some studies suggest higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%). 1 The benefit is small but risks are minimal, making this a reasonable option. 2

Mandatory Eye Protection

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent corneal damage—this is non-negotiable. 1, 2

Eye Protection Protocol

• Lubricating ophthalmic drops every 1-2 hours while awake 2
• Ophthalmic ointment at bedtime for sustained moisture retention 2
• Eye taping or patching at night (with careful instruction on proper technique to avoid corneal abrasion) 2
• Sunglasses outdoors to protect against wind and foreign particles 2
• Moisture chambers using polyethylene covers for severe cases 2

Urgent Ophthalmology Referral Indications

Refer immediately if: 2

• Complete inability to close the eye
• Eye pain, vision changes, or increasing redness
• Signs of corneal exposure or damage

Diagnostic Assessment

Before diagnosing Bell's palsy, exclude identifiable causes through history and physical examination: 5, 2

• Trauma (temporal bone fracture, surgical injury)
• Infection (Lyme disease, herpes zoster oticus, otitis media)
• Tumor (acoustic neuroma, parotid tumor, facial nerve schwannoma)
• Stroke (distinguish by forehead sparing in central lesions)

Key Physical Examination Features

• Forehead involvement distinguishes Bell's palsy from central causes 2
• Assess severity using House-Brackmann grading scale (Grade 1 = normal to Grade 6 = total paralysis) 2
• Test eye closure carefully to assess corneal exposure risk 2
• Check for bilateral involvement—rare in Bell's palsy and suggests alternative diagnosis 2

When to Order Testing

Routine laboratory testing and imaging are NOT recommended for typical Bell's palsy presentations. 1, 2

Order MRI with and without contrast if: 2

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

Follow-Up and Referral Algorithm

Mandatory Reassessment or Specialist Referral at 3 Months

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

Immediate Referral Triggers (Any Time Point)

• New or worsening neurologic findings 1, 2
• Development of ocular symptoms (pain, vision changes, persistent irritation) 1, 2
• Severe lagophthalmos requiring surgical intervention 2

Special Populations

Children

• Higher rates of spontaneous recovery (up to 90%) compared to adults 4
• Evidence for steroid benefit is less conclusive in pediatric patients 1, 2
• Consider oral steroids on an individualized basis with substantial caregiver participation in decision-making 2
• Recommended pediatric dose: Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours on an individualized basis with careful assessment of benefits and risks 2
• Combination therapy with antivirals may be considered on an individualized basis 2
• Eye protection is essential using the same protocol as non-pregnant patients 2

Expected Recovery Timeline

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

Long-Term Management for Incomplete Recovery

Reconstructive Options (After 3 Months)

For patients with persistent paralysis, refer to facial nerve specialist for: 2

• 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 lagophthalmos 2

Psychological Support

Screen for depression and provide psychological support—patients with persistent facial paralysis experience significant psychosocial dysfunction, difficulty expressing emotion, and social stigmatization. 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness dramatically 1
• Using antiviral monotherapy alone is completely ineffective 1, 4
• Failing to provide adequate eye protection can lead to permanent corneal damage 1
• Not testing forehead function can lead to misdiagnosis of central causes 2
• Failing to refer at 3 months delays access to reconstructive options 2
• Improper eye taping technique can cause corneal abrasion—patients must be carefully instructed 2

Therapies NOT Recommended

• Acupuncture: No recommendation can be made due to poor-quality trials 2
• Physical therapy: No recommendation can be made due to limited evidence (only case series) 2
• Surgical decompression: Rarely indicated except in specialized centers 2