What is the recommended management for Bell's palsy?

Management of Bell's Palsy

Start 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

Immediate Treatment (Within 72 Hours)

Corticosteroid Therapy (First-Line)

• Prescribe 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 effectiveness drops dramatically after 72 hours—do not delay 1

Antiviral Therapy (Optional Add-On)

• May offer valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days in combination with corticosteroids 1, 3
• Some evidence shows combination therapy achieves 96.5% complete recovery versus 89.7% with steroids alone, though the benefit is small 1
• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 3

Eye Protection (Critical for All Patients)

Assess Eye Closure Immediately

• Examine ability to close eyelid completely—incomplete closure (lagophthalmos) risks corneal damage 1
• Check for Bell's phenomenon (upward eye rotation with attempted closure)—this provides some protection but is insufficient alone 1

Implement Layered Protection Protocol

• Daytime: Lubricating eye drops every 1-2 hours while awake 1
• Nighttime: Ophthalmic ointment at bedtime for sustained moisture retention 1
• Outdoor: Sunglasses to protect against wind and foreign particles 1
• Severe cases: Eye taping or patching at night (instruct carefully on proper technique to avoid corneal abrasion) 1
• Very severe cases: Consider moisture chambers using polyethylene covers 1

Urgent Ophthalmology Referral If:

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, or discharge 1
• Signs of corneal exposure or damage 1

Diagnosis Confirmation

Clinical Diagnosis Criteria

• Acute onset (within 72 hours) of unilateral facial weakness involving the forehead 1, 3
• No other identifiable cause after thorough history and examination 1
• Distinguish from stroke: Bell's palsy affects the forehead, while central lesions (stroke) spare forehead function 1, 4

What NOT to Order

• Do not order routine laboratory tests or imaging for typical Bell's palsy 1
• Do not order electrodiagnostic testing for incomplete paralysis 1

When to Order Advanced Testing

• MRI with and without contrast if: 1

  • Second paralysis on same side
  • Isolated branch paralysis (not all facial muscles affected)
  • Other cranial nerve involvement
  • No recovery after 3 months
  • Bilateral facial weakness (very rare in Bell's palsy) 1
  • Associated symptoms suggesting central pathology (anomia, limb weakness, sensory changes) 4

• Electrodiagnostic testing (ENoG/EMG) may be offered if: 1

  • Complete facial paralysis present
  • Testing performed 3-14 days post-onset (unreliable before 7 days or after 21 days) 1

  • 10% nerve response amplitude indicates excellent prognosis; <10% carries 50% risk of incomplete recovery 1

Special Populations

Children

• Better prognosis than adults with up to 90-94% spontaneous recovery rates 1, 3
• Corticosteroid benefit is unproven in children—involve caregivers in shared decision-making 1
• If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper 1
• Still initiate within 72 hours if treatment chosen 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
• Eye protection measures are essential and safe in pregnancy 1
• May consider combination therapy with antivirals on individualized basis 1

Follow-Up and Monitoring

Mandatory Reassessment or Specialist Referral If:

• Incomplete facial recovery at 3 months after symptom onset 1
• New or worsening neurologic findings at any point 1
• Development of ocular symptoms at any point 1

Expected Recovery Timeline

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

Long-Term Management for Incomplete Recovery

Reconstructive Options (Refer to Facial Nerve Specialist)

• Static procedures: eyelid weights, brow lifts, static facial slings 1
• Dynamic procedures: dynamic facial slings, nerve transfers 1
• Tarsorrhaphy (partial eyelid closure) for persistent severe lagophthalmos 1
• Botulinum toxin injections for synkinesis (involuntary co-contraction of facial muscles) 1, 5

Psychosocial Support

• Screen for depression in patients with persistent paralysis 1
• Address difficulty expressing emotion and social stigmatization 1
• Refer for psychological support when quality of life is impaired 1

Common Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours eliminates treatment benefit 1
• Prescribing antivirals alone is completely ineffective 1, 3
• Failing to provide adequate eye protection leads to preventable corneal damage 1
• Missing central causes of facial weakness by not testing forehead function 1, 4
• Failing to refer at 3 months delays access to reconstructive options 1
• Improper eye taping technique can cause corneal abrasion—instruct carefully 1

Therapies NOT Recommended

• Acupuncture: No recommendation can be made due to poor-quality trials 1
• Physical therapy: Limited evidence, though may benefit patients with severe paralysis and developing synkinesis 1, 5, 3
• Surgical decompression: Rarely indicated except in specialized circumstances 1