What is the management of Bell's Palsy?

Management of Bell's Palsy

First-Line Treatment: Oral Corticosteroids

All patients 16 years and older with Bell's palsy should receive oral corticosteroids within 72 hours of symptom onset. 1

• Prednisolone 50 mg daily for 10 days OR Prednisone 60 mg daily for 5 days followed by a 5-day taper are the recommended regimens 1, 2
• Treatment beyond 72 hours is ineffective and should not be initiated 1, 3
• 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 2, 4

Rationale for Corticosteroids

The mechanism involves reducing inflammation and edema of the facial nerve within the bony canal, preventing permanent nerve damage. 1 The therapeutic window is narrow because inflammation peaks early in the disease course. 1

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Antiviral Therapy: Limited Role

Antiviral monotherapy should NEVER be prescribed for Bell's palsy—it is completely ineffective. 1, 2

Combination Therapy Considerations

• Combination therapy with antivirals plus corticosteroids may be offered as an option within 72 hours of symptom onset 1, 5
• Valacyclovir 1 g three times daily for 7 days OR Acyclovir 400 mg five times daily for 10 days are the recommended antiviral regimens 1, 5
• One study showed 96.5% complete recovery with combination therapy versus 89.7% with steroids alone, though this benefit is small 1
• The added benefit is minimal, and corticosteroids remain the cornerstone of treatment 1

Evidence Divergence

The highest quality randomized controlled trial found no benefit of acyclovir alone or in combination with prednisolone at 3 or 9 months. 4 However, some observational studies suggest potential benefit, particularly in elderly patients. 6 Given the minimal risk and potential small benefit, combination therapy may be considered but is not mandatory. 1

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Eye Protection: Critical for Preventing Corneal Damage

All patients with impaired eye closure require immediate implementation of eye protection measures. 1, 2

Daytime Protection

• Lubricating ophthalmic drops every 1-2 hours while awake to prevent corneal desiccation 1, 2
• Sunglasses outdoors to protect against wind, foreign particles, and UV exposure 1, 2

Nighttime Protection

• Ophthalmic ointment at bedtime for sustained moisture retention (causes temporary vision blurring) 1, 2
• 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 Indications

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

Common Pitfall: Improper eye taping technique can cause corneal abrasion—patients must receive detailed instruction on taping the eyelid closed without applying pressure to the globe. 1

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Diagnosis: Clinical Exclusion of Other Causes

Bell's palsy is diagnosed clinically after excluding identifiable causes of facial weakness. 2

Key Diagnostic Features

• Acute onset of unilateral facial weakness or paralysis developing over less than 72 hours 2
• Forehead involvement (distinguishes from central/stroke causes where forehead is spared) 2, 5
• Associated symptoms: ipsilateral ear/face pain, hyperacusis, taste disturbance on anterior two-thirds of tongue, dry eye/mouth 2

What to Exclude

• Trauma: temporal bone fracture, surgical injury 2
• Infection: Lyme disease, herpes zoster oticus (Ramsay Hunt syndrome), otitis media 2
• Tumor: acoustic neuroma, parotid tumor, facial nerve schwannoma 2
• Stroke: forehead sparing, other neurologic deficits 2

Testing NOT Recommended

• Routine laboratory testing and imaging are NOT indicated for typical Bell's palsy presentations 1, 2
• MRI with and without contrast is reserved for atypical features: bilateral weakness, isolated branch paralysis, other cranial nerve involvement, recurrent paralysis on same side, or no recovery after 3 months 2

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Electrodiagnostic Testing: Prognostic Tool for Complete Paralysis

• Offer electrodiagnostic testing (ENoG and EMG) to patients with complete facial paralysis 2
• Do NOT perform testing in patients with incomplete paralysis 2
• Optimal timing: 3-14 days post-onset (testing before 7 days or after 14-21 days is unreliable due to ongoing Wallerian degeneration) 2

Prognostic Interpretation

• >10% nerve response amplitude compared to unaffected side: excellent prognosis 2
• <10% function: up to 50% risk of incomplete recovery 2

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Special Populations

Children

• Higher rates of spontaneous recovery than adults (up to 90%) 5
• Evidence for steroid benefit in children is inconclusive 1, 2
• Consider oral corticosteroids on an individualized basis with caregiver involvement in shared decision-making 1
• Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper may be used for severe or complete paralysis if caregivers prefer intervention 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours on an individualized basis with careful assessment of benefits and risks 1
• Eye protection measures are essential and safe in pregnancy 1
• Combination therapy with antivirals may be considered on an individualized basis 1

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Follow-Up and Referral Triggers

Mandatory Reassessment or Specialist Referral

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

Specialist Referrals

• Facial nerve specialist or facial plastic surgeon for incomplete recovery at 3 months to evaluate reconstructive options 1
• Ophthalmology for persistent eye closure problems 1
• Psychology/psychiatry for depression screening in patients with persistent paralysis 1

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Long-Term Complications and Management

Natural History

• 70% of patients with complete paralysis recover completely within 6 months without treatment 2, 7
• 94% of patients with incomplete paralysis recover completely 2
• 30% may experience permanent facial weakness with muscle contractures 2
• Most patients begin showing recovery within 2-3 weeks 2

Synkinesis (Misdirected Nerve Regrowth)

• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis 3, 5
• Evidence for specific physical therapy protocols is limited 3

Surgical Options for Persistent Lagophthalmos (>3 months)

• Eyelid weight implantation to improve eye closure 1
• Tarsorrhaphy (temporary or permanent partial eyelid closure) for severe cases 1
• Static procedures: brow lifts, static facial slings 1
• Dynamic procedures: dynamic facial slings, nerve transfers 1

Psychosocial Impact

• Significant psychosocial dysfunction and diminished quality of life in patients with persistent paralysis 1
• Screen for depression and refer when needed 1
• Difficulty expressing emotion impairs social interaction and causes stigmatization 1

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Critical Pitfalls to Avoid

1. Delaying corticosteroid treatment beyond 72 hours eliminates therapeutic benefit 1, 3
2. Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2
3. Failing to provide adequate eye protection leads to corneal damage and potential vision loss 1
4. Not testing forehead function can lead to misdiagnosis of stroke as Bell's palsy 2
5. Failing to refer patients with incomplete recovery at 3 months delays access to reconstructive options 1
6. Neglecting psychological impact exacerbates depression and social isolation 1