What is the recommended treatment for a patient presenting with Bell's palsy?

Treatment of Bell's Palsy

Primary Treatment: Oral Corticosteroids

Oral corticosteroids should be prescribed within 72 hours of symptom onset for all Bell's palsy patients aged 16 years and older, as this is the only proven effective treatment that significantly improves facial nerve recovery. 1

Recommended Corticosteroid Regimens

• Prednisolone 50 mg daily for 10 days (preferred regimen) 1
• Alternative: Prednisone 60 mg daily for 5 days, followed by a 5-day taper 1

Evidence Supporting Corticosteroids

The evidence for corticosteroid efficacy is robust:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 1, 2
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 1, 2

This represents a strong recommendation based on high-quality randomized controlled trial data from 2007 that remains the cornerstone evidence for treatment 2.

Antiviral Therapy: Limited Role

Antiviral therapy alone should NEVER be prescribed for Bell's palsy, as it is completely ineffective as monotherapy. 1

Optional Combination Therapy

• Antivirals may be offered in addition to corticosteroids within 72 hours of symptom onset, though the added benefit is minimal 1
• Valacyclovir 1 g three times daily for 7 days OR Acyclovir 400 mg five times daily for 10 days 1, 3
• Some evidence suggests combination therapy achieves 96.5% complete recovery versus 89.7% with steroids alone, but this small benefit must be weighed against minimal risks 1

The 2007 landmark trial found no evidence of benefit from acyclovir alone or significant additional benefit when combined with prednisolone 2. The American Academy of Otolaryngology-Head and Neck Surgery classifies combination therapy as an "option" rather than a recommendation 1.

Eye Protection: Critical Component

All patients with impaired eye closure require aggressive eye protection to prevent corneal damage, which can lead to permanent vision loss. 1

Eye Protection Algorithm by Severity

Mild to Moderate Impairment:

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Ophthalmic ointment at bedtime for sustained moisture 1
• Sunglasses outdoors for protection against wind and particles 1

Moderate to Severe Impairment:

• All of the above PLUS:
• Eye taping or patching at night (with careful instruction on proper technique to avoid corneal abrasion) 1
• Moisture chambers using polyethylene covers for nighttime protection 1

Severe Impairment (Complete Inability to Close Eye):

• Urgent ophthalmology referral 1
• Consider botulinum toxin injections for temporary improvement 1
• Surgical options: tarsorrhaphy (partial eyelid closure) or eyelid weight implantation 1

Warning Signs Requiring Urgent Ophthalmology Referral

• Eye pain, vision changes, redness, discharge, foreign body sensation, or increasing irritation despite protection measures 1

Special Populations

Children (Under 16 Years)

Children have a better prognosis than adults with higher rates of spontaneous recovery (up to 90-94%), but the benefit of corticosteroid treatment in children remains inconclusive. 1, 3

• A 2022 randomized controlled trial in 187 children found no significant benefit from prednisolone at 1 month (49% recovery with prednisolone vs 57% with placebo) 4
• The vast majority of children recover without treatment 4
• If treatment is pursued, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper, with substantial caregiver participation in shared decision-making 1
• Eye protection remains essential regardless of treatment decision 1

Pregnant Women

Pregnant women should be treated with oral corticosteroids within 72 hours of symptom onset, with individualized assessment of benefits and risks. 1

• Pregnant women have excellent recovery rates (up to 90%) 3
• Combination therapy with antivirals may be considered on an individualized basis 1
• Eye protection is essential and safe in pregnancy 1

Diagnostic Testing: Generally NOT Recommended

Routine laboratory testing and diagnostic imaging are NOT recommended for typical Bell's palsy presentation. 1

When to Order Testing

MRI with and without contrast is indicated for:

• Atypical presentations (second paralysis on same side, isolated branch paralysis, other cranial nerve involvement) 1
• No recovery after 3 months 1
• Bilateral facial weakness (rare in Bell's palsy) 1
• New or worsening neurologic findings 1

Electrodiagnostic testing (performed 3-14 days post-onset):

• May be offered to patients with complete facial paralysis for prognostic information 1
• NOT recommended for incomplete facial paralysis 1
• Greater than 10% nerve response amplitude indicates excellent prognosis 1
• Less than 10% function carries up to 50% risk of incomplete recovery 1

Follow-Up and Referral Criteria

Mandatory Reassessment or Specialist Referral

Refer to facial nerve specialist or facial plastic surgeon if:

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

Long-Term Complications

• Approximately 30% of patients may experience permanent facial weakness with muscle contractures 1
• Patients with persistent paralysis require screening for depression and psychological support 1
• Reconstructive surgery options include static procedures (eyelid weights, brow lifts) and dynamic procedures (nerve transfers) 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness of corticosteroid therapy 1
• Using antiviral therapy alone is completely ineffective and delays appropriate treatment 1
• Failing to provide adequate eye protection can lead to permanent corneal damage 1
• Missing central causes of facial weakness by not testing forehead function (central lesions spare the forehead) 1
• Improper eye taping technique can cause corneal abrasion; patients must receive careful instruction 1
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1

Prognosis

Natural History Without Treatment:

• Approximately 70% of patients with complete paralysis recover completely within 6 months 1
• Patients with incomplete paralysis have recovery rates up to 94% 1, 3
• Most patients begin showing recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1

With Corticosteroid Treatment:

• Recovery rates significantly improve, with 94.4% complete recovery at 9 months 1, 2