What is the best management approach for Bell's palsy?

Management of Bell's Palsy

Immediate Treatment (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 that significantly improves complete recovery rates from 63.6% to 83% at 3 months and from 81.6% to 94.4% at 9 months. 1, 2

Corticosteroid Regimen

• Prednisolone 50 mg daily for 10 days (preferred) 1
• OR Prednisone 60 mg daily for 5 days, then taper by 10 mg daily over next 5 days 1, 3
• Treatment beyond 72 hours has no proven benefit 1

Antiviral Therapy Considerations

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 4
• 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
• The added benefit of combination therapy is minimal (96.5% vs 89.7% complete recovery), though risks are low 1
• Acyclovir alone showed no benefit in the landmark trial (71.2% recovery vs 75.7% without acyclovir, p=0.50) 2

Eye Protection (Critical for All Patients with Incomplete Eye Closure)

Implement aggressive eye protection immediately to prevent permanent corneal damage—this is non-negotiable for any patient with lagophthalmos. 1

Daytime Protection

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Sunglasses outdoors for wind and particle protection 1

Nighttime Protection

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

Urgent Ophthalmology Referral Triggers

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

Diagnosis and Initial Assessment

Clinical Diagnosis Criteria

• Acute onset (within 72 hours) of unilateral facial weakness involving the forehead 1
• No other identifiable cause after thorough history and examination 1
• Exclude trauma (temporal bone fracture, surgical injury), infection, tumor, stroke 1
• Bilateral weakness is rare and suggests alternative diagnosis (sarcoidosis, Lyme disease) 1

Testing NOT Recommended

• Routine laboratory testing is NOT indicated 1
• Diagnostic imaging is NOT indicated for typical presentations 1

When to Order MRI

• Recurrent paralysis on the same side 5
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• No recovery after 3 months 1
• Progressive worsening 1

Electrodiagnostic Testing

• Offer to patients with complete facial paralysis only 1
• Perform between 3-14 days post-onset for reliable prognostic information 1

• 10% nerve response amplitude indicates excellent prognosis 1

• <10% function predicts up to 50% risk of incomplete recovery 1
• Do NOT order for incomplete paralysis 1

Special Populations

Pediatric Patients

• Children have better prognosis with up to 90% spontaneous recovery 3
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider prednisolone 1 mg/kg/day (max 50-60 mg) for severe cases with substantial caregiver involvement in decision-making 1
• Still treat within 72-hour window if steroids are chosen 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
• Recovery rates up to 90% in pregnancy 3
• Eye protection measures are safe and essential 1
• Combination therapy with antivirals may be considered on case-by-case basis 1

Mandatory Follow-Up and Referral Triggers

At 3 Months

• Refer to facial nerve specialist if incomplete recovery persists 1, 5
• Consider reconstructive procedures: eyelid weights, brow lifts, static facial slings, nerve transfers 1

Immediate Referral Indications

• New or worsening neurologic findings at any point 1
• Development of ocular symptoms 1
• Recurrent paralysis on same side (mandates imaging and specialist evaluation) 5

Ophthalmology Referral

• Persistent lagophthalmos beyond 3 months 1
• Consider tarsorrhaphy or eyelid weight implantation for severe cases 1

Psychological Support

• Screen for depression in patients with persistent paralysis 1
• Address psychosocial dysfunction, difficulty expressing emotion, stigmatization 1

Prognosis and Recovery Timeline

Expected Recovery

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

Prognostic Factors

• Incomplete paralysis at presentation predicts better outcome 1
• Age >60 years may have worse prognosis without treatment 6
• Early corticosteroid treatment significantly improves outcomes across all age groups 2

Common Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours eliminates treatment benefit 1
• Prescribing antivirals alone is completely ineffective 1, 4
• Failing to implement eye protection risks permanent corneal damage 1
• Missing atypical features (recurrence, bilateral involvement, isolated branch) delays diagnosis of serious underlying pathology 1, 5
• Not referring at 3 months for incomplete recovery delays access to reconstructive options 1
• Improper eye taping technique can cause corneal abrasion 1