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

Treatment of Bell's Palsy

Oral corticosteroids prescribed within 72 hours of symptom onset are the cornerstone of Bell's palsy treatment, with prednisolone 50 mg daily for 10 days or prednisone 60-mg daily for 5 days followed by a 5-day taper, demonstrating 83% recovery at 3 months versus 63.6% with placebo. 1

Immediate Treatment Protocol (Within 72 Hours)

First-Line Therapy: Corticosteroids

• Initiate oral corticosteroids immediately for all patients 16 years and older with Bell's palsy presenting within 72 hours of symptom onset 1
• Recommended regimens: 1
  • Prednisolone 50 mg orally daily for 10 days, OR
  • Prednisone 60 mg orally daily for 5 days, then taper over 5 days
• Evidence demonstrates 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1
• Critical timing: Treatment beyond 72 hours shows no proven benefit and should not be initiated 1

Weight-Based Dosing Considerations

• For patients significantly above or below average weight, consider 1 mg/kg/day prednisone (maximum 60 mg/day) to ensure adequate dosing 1
• Standard methylprednisolone dose packs provide only 105 mg prednisone equivalent versus 540 mg over 14 days with proper dosing, representing significant underdosing 1

Optional Combination Therapy: Antivirals Plus Steroids

• May offer oral antiviral therapy in addition to corticosteroids within 72 hours, though the added benefit is minimal 1
• Combination therapy shows 96.5% complete recovery versus 89.7% with steroids alone—a small but potentially meaningful difference 1
• Antiviral options: 1
  • Valacyclovir 1 g orally three times daily for 7 days 2, OR
  • Acyclovir 400 mg orally five times daily for 10 days 1, 2
• Never prescribe antivirals as monotherapy—they are completely ineffective alone 1, 2

Mandatory Eye Protection (All Patients)

Immediate Implementation

Eye protection must be initiated immediately for all patients with impaired eye closure to prevent permanent corneal damage. 1

Daytime Protection Protocol

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1
• Use sunglasses outdoors to protect against wind and foreign particles 1
• Consider moisture chambers using polyethylene covers for severe cases 1

Nighttime Protection Protocol

• Apply ophthalmic ointment at bedtime for sustained moisture retention 1
• Use eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
• Moisture chambers are particularly effective for nighttime protection 1

Urgent Ophthalmology Referral Indications

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

Special Populations

Pediatric Patients (Under 16 Years)

• Children have better prognosis with higher spontaneous recovery rates (up to 90%) than adults 2
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis cases with substantial caregiver participation in shared decision-making 1
• Most children recover completely without treatment 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized assessment of benefits and risks 1
• Pregnant women have excellent recovery rates (up to 90%) 2
• Eye protection measures are essential and safe in pregnancy 1
• Combination therapy with antivirals may be considered on an individualized basis 1

Diagnostic Approach

Clinical Diagnosis

• Bell's palsy is a diagnosis of exclusion requiring acute onset (<72 hours) of unilateral facial weakness involving the forehead without identifiable cause 3, 2
• Thorough history and physical examination are essential to exclude alternative causes 1
• Routine laboratory testing and imaging are NOT recommended for typical presentations 1, 3

Red Flags Requiring Imaging (MRI with and without contrast)

• Recurrent paralysis on the same side 1
• Bilateral facial weakness 3
• Isolated branch paralysis 1
• Other cranial nerve involvement 1, 3
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1
• Additional neurologic symptoms (dizziness, dysphagia, diplopia, limb weakness) suggesting stroke 3

Distinguishing from Stroke

• Forehead involvement distinguishes Bell's palsy from stroke—central lesions spare the forehead 3
• Stroke typically presents with additional neurologic deficits, vascular risk factors, and other cranial nerve involvement 3
• Document function of all cranial nerves to exclude central causes 3

Follow-Up and Reassessment

Mandatory Follow-Up Timeline

• Initial visit within 72 hours for treatment initiation and eye care education 1
• Early follow-up at 1-2 weeks to assess recovery trajectory and reinforce eye protection 1
• Mandatory reassessment at 3 months for all patients with incomplete recovery 1

Urgent Reassessment Triggers (Any Time Point)

• New or worsening neurologic findings 1
• Development of ocular symptoms 1
• Progressive weakness beyond 3 weeks 1

Specialist Referral at 3 Months

• Refer patients with incomplete facial recovery at 3 months to a facial nerve specialist or facial plastic surgeon 1
• Ophthalmology referral for persistent eye closure problems 1
• Consider reconstructive options including static procedures (eyelid weights, brow lifts) or dynamic procedures (nerve transfers) 1
• Screen for depression and provide psychological support—patients experience significant psychosocial dysfunction 1

Electrodiagnostic Testing

Indications and Timing

• Offer electrodiagnostic testing (ENoG and EMG) to patients with complete facial paralysis 1
• Do NOT perform in patients with incomplete facial paralysis 1
• Testing is most reliable when performed 3-14 days post-onset 1
• Testing before 7 days or after 14-21 days provides unreliable prognostic information 1

Prognostic Interpretation

• 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

Prognosis

Expected Recovery Rates

• Approximately 70% of patients with complete paralysis recover completely within 6 months 1, 2
• Patients with incomplete paralysis have recovery rates up to 94% 1, 2
• Most patients begin showing recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1
• 30% may experience permanent facial weakness with muscle contractures 1

Factors Predicting Better Recovery

• Incomplete paralysis at presentation 1
• Younger age (children have better outcomes) 1, 2
• Early corticosteroid treatment 1
• Electrodiagnostic testing showing >10% nerve response 1

Therapies NOT Recommended

Ineffective or Unproven Treatments

• Physical therapy: No proven benefit over spontaneous recovery 1, 4
• Acupuncture: Poor-quality evidence with indeterminate benefit-harm ratio 1
• Antiviral monotherapy: Completely ineffective and should never be prescribed alone 1, 2
• Surgical decompression: Rarely indicated except in specialized cases 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates proven benefit 1
• Prescribing antivirals alone is ineffective and delays appropriate treatment 1
• Using standard methylprednisolone dose packs results in significant underdosing 1
• Failing to implement immediate eye protection can lead to permanent corneal damage 1
• Missing atypical features (bilateral weakness, other cranial nerve involvement, progressive symptoms) that suggest alternative diagnoses 1, 3
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1
• Improper eye taping technique can cause corneal abrasion—patients require careful instruction 1
• Overlooking psychological impact can exacerbate depression and social isolation 1