What is the recommended management for 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 treatment proven to significantly improve 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 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, 2
• Treatment beyond 72 hours is not supported by evidence and should not be initiated 1

Antiviral Therapy Considerations

• Never prescribe antiviral monotherapy—it is completely ineffective 1, 3
• May offer combination therapy (oral corticosteroids + antivirals) within 72 hours as an option, though benefit is small 1
• If choosing 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 or added to prednisolone 2, though some smaller studies suggest modest benefit with combination therapy 4, 5

Eye Protection (Critical for All Patients)

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

Daytime Protection

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Sunglasses outdoors to protect 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 Indications

• Complete inability to close the eye 1
• Any signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1
• Development of ocular symptoms at any point during recovery 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 forehead (distinguishes from central causes) 1, 3
• No identifiable cause after thorough history and physical examination 1

Red Flags Requiring 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
• Worsening symptoms 1

Special Populations

Children

• Better prognosis than adults with higher spontaneous recovery rates (up to 90%) 3
• Evidence for corticosteroid benefit is inconclusive in pediatrics 1
• Consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe/complete paralysis with substantial caregiver involvement in shared decision-making 1
• Most children recover completely without treatment 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
• Combination therapy with antivirals may be considered on an individualized basis 1
• Eye protection measures are essential and safe 1

Follow-Up and Reassessment

Mandatory Reassessment or Specialist Referral at 3 Months

Refer any patient with incomplete facial recovery at 3 months to a facial nerve specialist or facial plastic surgeon. 1

Immediate Referral Triggers (Any Time Point)

• New or worsening neurologic findings 1
• Development of ocular symptoms 1
• Persistent lagophthalmos requiring surgical intervention 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

Long-Term Management for Incomplete Recovery

Reconstructive Options (After 3 Months)

• Static procedures: eyelid weights, brow lifts, static facial slings 1
• Dynamic procedures: dynamic facial slings, nerve transfers 1
• Tarsorrhaphy for persistent severe lagophthalmos 1
• Botulinum toxin injections for synkinesis 1

Synkinesis Management

• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis, though evidence is limited 6, 3
• Early identification improves outcomes and quality of life 6

Psychological Support

• Screen for depression in patients with persistent paralysis 1
• Address psychosocial dysfunction and diminished quality of life 1
• Refer to specialist when needed 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates effectiveness 1
• Using antiviral monotherapy is completely ineffective 1, 3
• Failing to provide adequate eye protection can cause permanent corneal damage 1
• Improper eye taping technique can cause corneal abrasion—careful instruction is essential 1
• Failing to refer at 3 months delays access to reconstructive options 1
• Ordering routine labs and imaging for typical presentations wastes resources 1
• Restarting or extending corticosteroids beyond initial 10-day course has no evidence support 7