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 proven effective treatment that significantly improves complete recovery rates from 63.6% to 83% at 3 months. 1, 2

Immediate Treatment (Within 72 Hours)

First-Line Therapy: Corticosteroids

• Prescribe prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 3, 1, 4
• Treatment beyond 72 hours is ineffective—do not delay 3, 1, 4
• Evidence shows 94.4% complete recovery at 9 months with prednisolone versus 81.6% without treatment 1, 2

Antiviral Therapy Considerations

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 3, 1, 4
• May add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids, though added benefit is minimal 1, 5
• One study showed combination therapy achieved 96.5% complete recovery versus 89.7% with steroids alone, but this small benefit must be weighed against minimal risks 4, 6

Essential Eye Protection (All Patients with Incomplete Eye Closure)

Implement aggressive eye protection immediately to prevent permanent corneal damage—this is non-negotiable. 1, 4

Daytime Protection

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1
• Use sunglasses outdoors for wind and particle protection 1
• Consider moisture chambers with polyethylene covers for severe cases 3, 1

Nighttime Protection

• Apply ophthalmic ointment at bedtime for sustained moisture 3, 1
• Use eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 3, 1

Urgent Ophthalmology Referral Indications

• 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 3

Diagnostic Assessment

Clinical Diagnosis

• Bell's palsy presents as acute unilateral facial weakness developing over less than 72 hours, involving the forehead (distinguishing it from central causes) 1, 5
• Associated symptoms include ipsilateral ear/face pain, hyperacusis, taste disturbance on anterior two-thirds of tongue, and dry eye/mouth 1

Testing NOT Recommended

• Do not order routine laboratory tests or imaging for typical presentations 1, 4
• Electrodiagnostic testing may be offered only for complete facial paralysis, performed 3-14 days post-onset 1

When to Order MRI

• Obtain MRI with and without contrast for: 1
  • Second paralysis on same side
  • Isolated branch paralysis
  • Other cranial nerve involvement
  • No recovery after 3 months
  • Bilateral facial weakness (rare in Bell's palsy) 1

Special Populations

Children

• Children have better prognosis with up to 90% spontaneous recovery 5
• Evidence for corticosteroid benefit in children is inconclusive 1, 4
• Consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for severe cases with substantial caregiver involvement in decision-making 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

Mandatory Follow-Up and Referral Triggers

Refer to Facial Nerve Specialist If:

• Incomplete facial recovery at 3 months after symptom onset 3, 1, 4
• New or worsening neurologic findings at any point 3, 1, 4
• Development of ocular symptoms at any point 3, 1, 4

Long-Term Management for Incomplete Recovery

• Facial nerve specialist or facial plastic surgeon for reconstructive options (static procedures like eyelid weights, brow lifts, facial slings; dynamic procedures like nerve transfers) 1
• Ophthalmology for persistent lagophthalmos—consider tarsorrhaphy or eyelid weight implantation 3, 1
• Screen for depression and provide psychological support—persistent paralysis significantly impairs quality of life 1

Prognosis

Expected Recovery Rates

• Incomplete paralysis at presentation: up to 94% complete recovery 1
• Complete paralysis: approximately 70% complete recovery within 6 months 1
• Most patients begin recovery within 2-3 weeks, with complete recovery typically by 3-4 months 1
• 30% may experience permanent facial weakness with muscle contractures 1

Prognostic Indicators

• Incomplete paralysis predicts faster and more complete recovery 1
• Electrodiagnostic testing showing >10% nerve response amplitude indicates excellent prognosis 1
• Complete paralysis with <10% function carries up to 50% risk of incomplete recovery 1

Critical Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours eliminates treatment effectiveness 3, 1, 4
• Prescribing antivirals alone is completely ineffective 3, 1, 4
• Inadequate eye protection leads to permanent corneal damage 3, 1, 4
• Failing to refer at 3 months delays reconstructive options 1
• Ordering unnecessary laboratory tests and imaging for typical presentations wastes resources 1, 4