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

Management and Treatment of Bell's Palsy

Immediate Treatment: Corticosteroids Within 72 Hours

Oral corticosteroids should be prescribed within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy, 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 1
• OR Prednisone 60 mg daily for 5 days followed by a 5-day taper 1

Evidence Supporting Corticosteroids:

• 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1
• Treatment beyond 72 hours has no proven benefit 1

Weight-Based Dosing Considerations:

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

Antiviral Therapy: Optional Addition, Never Alone

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

Combination Therapy Option:

• May offer oral antivirals in addition to corticosteroids within 72 hours 1
• Potential benefit is small: 96.5% complete recovery with combination versus 89.7% with steroids alone 1
• Recommended antivirals if used: 2
  • Valacyclovir 1 g three times daily for 7 days
  • OR Acyclovir 400 mg five times daily for 10 days 1

The benefit of adding antivirals is minimal, and corticosteroids remain the cornerstone of treatment. 1

Eye Protection: Critical to Prevent Permanent Corneal Damage

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

Daytime Protection:

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Sunglasses outdoors to protect against wind and foreign particles 1

Nighttime Protection:

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

Urgent Ophthalmology Referral Indications:

• Complete inability to close the eye 1
• Signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1
• Development of any ocular symptoms at any point 1

Common Eye Protection Pitfall:

Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction. 1 Relying solely on drops without nighttime protection can lead to exposure keratitis. 1

Diagnosis: Clinical Diagnosis of Exclusion

Bell's palsy is diagnosed clinically when acute unilateral facial weakness involving the forehead develops within 72 hours without an identifiable cause. 1, 3

Key Diagnostic Features:

• Unilateral facial weakness involving the forehead (distinguishes from stroke, which spares forehead) 1, 3
• Rapid onset within 72 hours 3
• May include ipsilateral ear/facial pain, taste disturbance, hyperacusis, dry eye/mouth 1, 3

Differential Diagnoses to Exclude:

• Stroke: Look for forehead sparing, other neurologic deficits, limb weakness, speech difficulties 3
• Trauma: Temporal bone fracture, surgical injury 1
• Infection: Lyme disease, herpes zoster, sarcoidosis 3
• Tumor: Brain, parotid gland, infratemporal fossa, cancer involving facial nerve 3

Testing NOT Recommended:

Routine laboratory testing and diagnostic imaging are NOT recommended for typical Bell's palsy presentations. 1, 3

When Imaging IS Indicated (MRI with and without contrast):

• Atypical presentations 1
• Recurrent paralysis on same side 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Bilateral facial weakness 3
• Progressive weakness beyond 3 weeks 1
• No sign of recovery after 3 months 1

Electrodiagnostic Testing:

• May be offered to patients with complete facial paralysis 1
• NOT recommended for incomplete paralysis 1
• Most reliable when performed 3-14 days post-onset 1

• 10% nerve response amplitude indicates excellent prognosis 1

• <10% function carries up to 50% risk of incomplete recovery 1

Special Populations

Pregnant Women:

Pregnant women should be treated with oral corticosteroids within 72 hours using individualized risk-benefit assessment. 1 Eye protection measures are essential and safe in pregnancy. 1

Children:

• Children have better prognosis with higher spontaneous recovery rates than adults 1
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider oral corticosteroids on 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 if treatment chosen 1

Follow-Up and Reassessment

Mandatory Reassessment or Specialist Referral Triggers:

• 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

Recommended 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

Prognosis and Natural History

Recovery Rates:

• Patients with incomplete paralysis: Up to 94% complete recovery 1, 2
• Patients with complete paralysis: Approximately 70% complete recovery within 6 months 1
• 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

Prognostic Factors:

• Incomplete paralysis at presentation predicts faster and more complete recovery 1
• Children have better prognosis than adults 1
• Electrodiagnostic testing showing >10% nerve response amplitude indicates excellent prognosis 1

Long-Term Management for Incomplete Recovery

Reconstructive Surgery Options (after 3 months):

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

Long-Term Complications Requiring Management:

• Persistent incomplete eye closure with corneal damage risk 1
• Lacrimal dysfunction (dry eye) 1
• Nasal airway obstruction 1
• Oral incompetence affecting eating, drinking, speaking 1
• Psychosocial dysfunction, depression, social isolation 1

Patients with persistent facial paralysis require screening for depression and referral when needed. 1

Therapies NOT Recommended

Strong Recommendations Against:

• Physical therapy: No proven benefit over spontaneous recovery 1, 2
• Acupuncture: Poor quality evidence with indeterminate benefit-harm ratio 1
• Antiviral monotherapy: Completely ineffective 1, 2
• Surgical decompression: Rarely indicated except in specialized circumstances 1

Critical Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates effectiveness 1
• Prescribing antivirals alone is ineffective and delays appropriate treatment 1
• Using standard methylprednisolone dose packs results in significant underdosing 1
• Inadequate eye protection monitoring can lead to permanent corneal damage 1
• Failing to refer at 3 months delays access to reconstructive options 1
• Missing atypical features (bilateral weakness, isolated branch paralysis, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 3
• Overlooking forehead involvement can lead to misdiagnosis of stroke 3