What is the recommended treatment for a patient with Bell's palsy, considering factors such as symptom onset, underlying health conditions like diabetes or hypertension, and potential for permanent nerve damage?

Treatment of Bell's Palsy

Prescribe oral corticosteroids (prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper) within 72 hours of symptom onset for all patients 16 years and older, and implement immediate eye protection measures for those with impaired eye closure. 1

Initial Assessment and Diagnosis

• Perform a focused history and physical examination to exclude other causes of facial paralysis, specifically assessing for trauma (temporal bone fracture), infection, tumor, or stroke 2, 1
• Confirm unilateral facial weakness involving the forehead (distinguishing from central causes which spare the forehead), with symptom onset within 72 hours 1
• Assess severity using the House-Brackmann grading system (grades 1-6) to document baseline function 1
• Do NOT obtain routine laboratory testing or diagnostic imaging for typical presentations of Bell's palsy 2, 1

First-Line Treatment: Corticosteroids

Corticosteroids are the only proven effective treatment and must be initiated within 72 hours of symptom onset. 1, 3

• Prednisolone 50 mg orally daily for 10 days (preferred regimen) 1
• Alternative: Prednisone 60 mg orally daily for 5 days, then taper by 10 mg daily over 5 days 1
• 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 1, 3
• Treatment beyond 72 hours significantly reduces effectiveness 1

Antiviral Therapy Considerations

Never prescribe antiviral therapy alone—it is completely ineffective as monotherapy. 2, 1

• Combination therapy (corticosteroids + antivirals) may be offered as an option within 72 hours, though the added benefit is minimal 2, 1
• If choosing combination therapy: valacyclovir 1 g orally three times daily for 7 days OR acyclovir 400 mg orally five times daily for 10 days 1, 4
• Some evidence suggests slightly higher complete recovery rates with combination therapy (96.5%) versus steroids alone (89.7%), but this benefit is small 1, 5

Eye Protection: Critical and Non-Negotiable

All patients with impaired eye closure require immediate and aggressive eye protection to prevent permanent corneal damage. 2, 1

Daytime Protection

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1
• Use sunglasses outdoors for protection against wind and foreign particles 1

Nighttime Protection

• Apply ophthalmic ointment at bedtime for sustained moisture retention 1
• Consider eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
• Use moisture chambers with polyethylene covers for severe cases 1

Urgent Ophthalmology Referral Indications

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

Special Populations

Children

• Children have better prognosis than adults with higher spontaneous recovery rates (up to 90%) 1, 4
• Evidence for corticosteroid benefit in children is less conclusive than in adults 1
• Consider oral corticosteroids on an individualized basis with substantial caregiver involvement in shared decision-making 1
• Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper if treatment is chosen 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using the same regimens as non-pregnant adults 1
• Perform careful individualized assessment of benefits and risks 1
• Eye protection measures are essential and safe in pregnancy 1

Patients with Diabetes or Hypertension

• These comorbidities do not contraindicate short-term corticosteroid use 1
• Monitor blood glucose closely in diabetic patients during steroid treatment
• The 10-day treatment course is brief enough that cardiovascular risks are minimal

Electrodiagnostic Testing

Do NOT perform electrodiagnostic testing in patients with incomplete facial paralysis. 2, 1

• May offer electrodiagnostic testing (electroneurography and electromyography) only to patients with complete facial paralysis 2, 1
• Testing is most reliable when performed 3-14 days post-onset (before 7 days or after 14-21 days provides unreliable prognostic information) 1
• Greater than 10% nerve response amplitude compared to unaffected side indicates excellent prognosis 1
• Less than 10% function carries up to 50% risk of incomplete recovery 1

Therapies NOT Recommended

• Antiviral monotherapy: strongly contraindicated 2, 1
• Surgical decompression: no recommendation can be made; rarely indicated except in specialized circumstances 2, 1
• Acupuncture: no recommendation can be made due to poor-quality evidence 2, 1
• Physical therapy: no recommendation can be made due to limited evidence 2, 1
• Electrical nerve stimulation: no specific recommendation; unproven benefit 6

Mandatory Follow-Up and Referral Triggers

Reassess or refer to a facial nerve specialist for: 2, 1

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

At 3-Month Mark with Incomplete Recovery

• Refer to facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options 1
• Refer to ophthalmology for persistent eye closure problems 1
• Consider MRI with and without contrast to exclude other causes 1
• Screen for depression and provide psychological support, as persistent facial paralysis significantly impacts quality of life 1

Prognosis and Natural History

• Patients with incomplete paralysis at presentation have excellent prognosis with up to 94% complete recovery 1
• Patients with complete paralysis have approximately 70% complete recovery within 6 months 1
• Most patients begin showing recovery within 2-3 weeks, with complete recovery typically within 3-4 months 1
• Approximately 30% of patients may experience permanent facial weakness with muscle contractures 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates the therapeutic window 1
• Prescribing antivirals alone is completely ineffective and delays appropriate treatment 1
• Failing to implement aggressive eye protection can result in permanent corneal damage 1
• Not referring patients with incomplete recovery at 3 months delays access to reconstructive options 1
• Ordering routine laboratory tests or imaging wastes resources and delays treatment 2, 1
• Performing electrodiagnostic testing on patients with incomplete paralysis provides no useful information 2, 1