What is the management of Bell’s palsy?

Bell's Palsy: Presentation and Management

Clinical Presentation

Bell's palsy presents as acute onset unilateral facial weakness or paralysis developing over less than 72 hours, characteristically involving the forehead, distinguishing it from central causes of facial weakness. 1

Key Physical Examination Findings

• Facial weakness involves the forehead (inability to raise eyebrow, wrinkle forehead), which is the critical distinguishing feature from stroke 1, 2
• Incomplete eye closure (lagophthalmos) with Bell's phenomenon (upward eye rotation during attempted closure) 1
• Oral incompetence manifesting as drooling, difficulty with eating and drinking 1
• Severity grading using House-Brackmann scale (Grade 1 = normal to Grade 6 = complete paralysis) 1

Associated Symptoms

• Ipsilateral ear or facial pain occurring in many patients 1
• Hyperacusis (increased sound sensitivity) from stapedius muscle involvement 1
• Taste disturbance on anterior two-thirds of tongue 1
• Dry eye and mouth from autonomic fiber dysfunction 1

Red Flags Requiring Alternative Diagnosis

• Bilateral facial weakness suggests alternative diagnosis 1
• Gradual onset beyond 72 hours is atypical 1
• Other cranial nerve involvement requires imaging 1
• Recurrent paralysis on same side mandates MRI evaluation 1

Acute Management Algorithm

Step 1: Diagnostic Assessment (Within 72 Hours)

Perform focused history and physical examination to exclude identifiable causes before diagnosing Bell's palsy. 3, 1

• Exclude trauma (temporal bone fracture, surgical injury) 1
• Exclude infection (Lyme disease, herpes zoster, otitis media) 1
• Exclude tumor (parotid, acoustic neuroma) 1
• Exclude stroke (forehead sparing indicates central lesion) 1

Do NOT order routine laboratory testing or imaging for typical Bell's palsy presentation. 1

Step 2: Initiate Corticosteroid Therapy (Within 72 Hours)

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older—this is the only proven effective treatment. 4, 1, 5

Recommended Regimens:

• Prednisolone 50 mg daily for 10 days (preferred) 4, 1
• OR Prednisone 60 mg daily for 5 days, then 5-day taper 4, 1

Evidence Supporting Steroids:

• 83% recovery at 3 months with prednisolone vs 63.6% with placebo 1, 5
• 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1, 5

Step 3: Consider Antiviral Therapy (Optional)

Antiviral therapy alone is ineffective and should NEVER be prescribed as monotherapy. 4, 1

You may offer combination therapy (steroids plus antivirals) within 72 hours, though the added benefit is minimal. 1, 2

If Prescribing Combination Therapy:

• Valacyclovir 1 g three times daily for 7 days 2
• OR Acyclovir 400 mg five times daily for 10 days 1, 2

Evidence shows 96.5% complete recovery with combination therapy vs 89.7% with steroids alone, but this small benefit must be weighed against minimal risks. 1

Step 4: Implement Eye Protection (Mandatory for All Patients)

All patients with impaired eye closure require aggressive eye protection to prevent corneal damage—this is non-negotiable. 4, 1

Daytime Protection:

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Sunglasses outdoors to protect against wind and particles 1

Nighttime Protection:

• Ophthalmic ointment at bedtime for sustained moisture 1
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
• Moisture chambers using polyethylene covers for severe cases 1

Urgent Ophthalmology Referral Indications:

• Complete inability to close eye 1
• Eye pain, vision changes, or redness 6
• Signs of corneal exposure or damage 1

Special Populations

Children

Children have better prognosis than adults with recovery rates up to 90%, but evidence for steroid benefit in pediatrics is inconclusive. 1, 2

• Consider oral corticosteroids on case-by-case basis with substantial caregiver involvement in decision-making 1
• Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, then 5-day taper if treatment chosen 1
• Do NOT prescribe beyond 72-hour window as no evidence supports delayed treatment 1

Pregnant Women

Treat pregnant women with oral corticosteroids within 72 hours using individualized risk-benefit assessment. 1

• Eye protection measures are essential and safe in pregnancy 1
• Combination therapy with antivirals may be considered on case-by-case basis 1

Follow-Up and Monitoring

Mandatory Reassessment or Referral Triggers

Refer to facial nerve specialist or ophthalmologist for: 4, 1

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

Electrodiagnostic Testing

Offer electrodiagnostic testing (ENoG and EMG) to patients with complete facial paralysis, performed 3-14 days post-onset. 1

• >10% nerve response amplitude indicates excellent prognosis 1
• <10% function carries up to 50% risk of incomplete recovery 1
• Testing before 7 days or after 14-21 days provides unreliable information due to ongoing Wallerian degeneration 1

Advanced Imaging Indications

Order MRI with and without contrast for: 1

• No recovery after 3 months 1
• Worsening symptoms 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1

Long-Term Management (Beyond 3 Months)

For Patients with Incomplete Recovery

Refer to facial nerve specialist or facial plastic surgeon at 3 months for evaluation of reconstructive options. 1

Surgical Options:

• Eyelid weight implantation for persistent lagophthalmos 1
• Tarsorrhaphy (partial eyelid closure) for severe eye exposure 1
• Static procedures (brow lifts, facial slings) for cosmetic improvement 1
• Dynamic procedures (nerve transfers) for functional restoration 1

Synkinesis Management

Physical therapy may benefit patients with severe paralysis and developing synkinesis, though evidence for specific protocols is limited. 4

Psychological Support

Screen for depression and refer to appropriate specialist—patients with persistent paralysis experience significant psychosocial dysfunction. 1

• Difficulty expressing emotion impairs social interaction 1
• Stigmatization due to facial appearance is common 1

Expected Recovery Timeline

Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 6

• Patients with incomplete paralysis: up to 94% complete recovery 1, 2
• Patients with complete paralysis: approximately 70% complete recovery within 6 months 1
• 30% may experience permanent facial weakness with muscle contractures 1

Critical Pitfalls to Avoid

• Never prescribe antiviral monotherapy—it is completely ineffective 4, 1
• Never delay steroid treatment beyond 72 hours—effectiveness dramatically decreases 4, 1
• Never neglect eye protection even if patient's primary complaint is pain 6
• Never fail to refer at 3 months with incomplete recovery—delays access to reconstructive options 1
• Never restart or extend corticosteroids beyond initial 10-day course—no evidence supports this 6
• Never order routine labs or imaging for typical presentation—this wastes resources 1