Treatment of Bell's Palsy
Primary Treatment Recommendation
Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy. 1, 2
The recommended regimen is:
- 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
This is the only proven effective treatment, with 83% complete recovery at 3 months (versus 63.6% with placebo) and 94.4% recovery at 9 months (versus 81.6% with placebo). 2, 3
Critical Timing Window
Do not initiate corticosteroids beyond 72 hours of symptom onset - there is no evidence supporting benefit after this window, and you expose patients to medication risks without meaningful benefit. 1, 2
If a patient presents at day 5 or later, focus exclusively on supportive care rather than steroids. 1
Antiviral Therapy Considerations
Monotherapy: Never Use
Never prescribe antiviral therapy alone - it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 4
Combination Therapy: Optional with Minimal Benefit
You may offer oral antivirals in addition to corticosteroids within 72 hours, though the added benefit is small. 2, 4
If choosing combination therapy:
- Valacyclovir 1 g three times daily for 7 days, OR 4
- Acyclovir 400 mg five times daily for 10 days 2, 4
The evidence shows combination therapy may reduce synkinesis rates and achieve slightly higher recovery (96.5% versus 89.7% with steroids alone), but corticosteroids remain the cornerstone. 2, 4
Essential Eye Protection (All Patients with Impaired Eye Closure)
Implement aggressive eye protection immediately to prevent corneal damage, which can occur rapidly and cause permanent vision loss. 1, 2
Daytime Protection
- Lubricating ophthalmic drops every 1-2 hours while awake 2, 5
- Sunglasses outdoors to protect against wind and foreign particles 2, 5
Nighttime Protection
- Ophthalmic ointment at bedtime for sustained moisture retention 1, 2, 5
- Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
- Moisture chambers using polyethylene covers for severe cases 1, 2
Urgent Ophthalmology Referral Needed For:
- Complete inability to close the eye 2
- Eye pain, vision changes, redness, or discharge 1
- Signs of corneal exposure or damage 2
Diagnostic Testing: What NOT to Do
Do not order routine laboratory testing or imaging for typical Bell's palsy presentation. 2
When Imaging IS Indicated:
Order MRI with and without contrast if: 2
- Second paralysis on the same side 2
- Isolated branch paralysis (not complete facial involvement) 2
- Other cranial nerve involvement 2
- No recovery after 3 months 2
- Bilateral facial weakness 2
Electrodiagnostic Testing
Offer electrodiagnostic testing only to patients with complete facial paralysis, performed 3-14 days post-onset for reliable prognostic information. 2
- Greater than 10% nerve response amplitude = excellent prognosis 2
- Less than 10% function = up to 50% risk of incomplete recovery 2
Special Populations
Children
- Better prognosis than adults with higher spontaneous recovery rates (up to 94%) 1, 2
- Evidence for corticosteroid benefit in children is inconclusive 1, 2
- Consider oral corticosteroids on an individualized basis with substantial caregiver participation in shared decision-making 2
- If treating: 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 using the same regimen as non-pregnant adults 1, 2
- Eye protection measures are essential and safe in pregnancy 2
- Recovery rates up to 90% in pregnant women 4
Follow-Up and Mandatory Referral Triggers
Reassess or Refer Immediately If:
- New or worsening neurologic findings at any point 1, 2, 5
- Development of ocular symptoms at any point 1, 2, 5
- Incomplete facial recovery at 3 months after symptom onset 1, 2, 5
Expected Recovery Timeline
- Most patients begin showing recovery within 2-3 weeks 1, 5
- Complete recovery typically occurs within 3-4 months 1, 5
- 70% with complete paralysis recover fully within 6 months 1, 2
- 94% with incomplete paralysis recover fully 1, 2
Long-Term Management for Incomplete Recovery
At 3 Months Without Complete Recovery:
Refer to facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options. 2, 5
Surgical Options Include:
- Eyelid weight implantation for persistent lagophthalmos 1, 2
- Tarsorrhaphy (temporary or permanent partial eyelid closure) for severe cases 1, 2
- Static procedures (brow lifts, static facial slings) 2
- Dynamic procedures (nerve transfers, dynamic facial slings) 2
Psychological Support
Screen for depression in patients with persistent paralysis - they experience significant psychosocial dysfunction, difficulty expressing emotion, and social stigmatization requiring active management. 2
Physical Therapy Considerations
Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited. 5, 4
The American Academy of Otolaryngology-Head and Neck Surgery notes no formal recommendation can be made due to limited evidence, but local heat therapy, massage, exercises, and biofeedback training may have a role. 2, 6
Common Pitfalls to Avoid
- Starting steroids beyond 72 hours - provides minimal benefit and exposes patients to medication risks 1, 2
- Prescribing antiviral monotherapy - completely ineffective and delays appropriate treatment 1, 2, 4
- Inadequate eye protection - can lead to permanent corneal damage within days 1, 2
- Failing to refer at 3 months - delays access to reconstructive options and psychological support 2, 5
- Restarting or extending corticosteroids beyond the initial 10-day course - no evidence supports this 5