Bell's Palsy Treatment
Prescribe oral corticosteroids immediately—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, as this significantly improves facial nerve recovery (83% vs 63.6% with placebo at 3 months). 1, 2
Immediate Management Algorithm
First 72 Hours: Critical Treatment Window
Corticosteroid therapy is the only proven effective treatment and must be initiated within 72 hours: 1, 2
- Prednisolone 50 mg daily for 10 days (preferred regimen) 1, 2
- Alternative: Prednisone 60 mg daily for 5 days, then 5-day taper 1, 2
- Evidence shows 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 2
Combination therapy with antivirals may be offered as an option: 2
- Valacyclovir 1 g three times daily for 7 days 3
- OR Acyclovir 400 mg five times daily for 10 days 2, 3
- Provides modest additional benefit (96.5% complete recovery vs 89.7% with steroids alone) 1
- Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 2, 3
Eye Protection: Mandatory and Immediate
Implement comprehensive eye protection immediately to prevent permanent corneal damage: 1, 2
- Lubricating ophthalmic drops every 1-2 hours while awake 2
- Sunglasses outdoors for wind and particle protection 1, 2
- Ophthalmic ointment at bedtime for sustained moisture 1, 2
- Eye taping or patching (with careful instruction to avoid corneal abrasion) 1, 2
- Moisture chambers using polyethylene covers for severe cases 2
Urgent ophthalmology referral if: 2
- Complete inability to close eye 2
- Eye pain, vision changes, redness, or discharge 2
- Signs of corneal exposure or damage 2
Diagnostic Confirmation
Bell's palsy is a diagnosis of exclusion requiring rapid onset (<72 hours) of unilateral facial weakness involving the forehead: 1, 2
Key diagnostic features: 1, 2, 4
- Entire ipsilateral face affected (forehead, eye closure, mouth) 1
- May include ipsilateral ear/facial pain, taste disturbance, hyperacusis, dry eye 1, 2
- No other neurologic abnormalities 5, 3
Do NOT order routine labs or imaging for typical presentations 1, 2
Red Flags Requiring Imaging (MRI with/without contrast)
Atypical features mandating further workup: 1, 2
- Bilateral facial weakness (suggests Lyme disease, sarcoidosis, Guillain-Barré) 1
- Other cranial nerve involvement 1, 2
- Progressive weakness beyond 3 weeks 2
- Recurrent paralysis on same side 2
- Isolated branch paralysis 2
- Additional neurologic symptoms (dizziness, dysphagia, diplopia, extremity weakness) 1
Special Populations
Children
Consider corticosteroids on individualized basis with substantial caregiver involvement in decision-making: 2
- Children have better prognosis (up to 90% complete recovery) 3
- Pediatric-specific evidence for steroids is inconclusive 2
- If treating: Prednisolone 1 mg/kg/day (max 50-60 mg) for 5 days, then 5-day taper 2
- Never delay beyond 72 hours 2
Pregnant Women
Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment: 2
- Pregnancy increases Bell's palsy incidence 4, 6
- Eye protection measures are essential and safe 2
- Combination therapy with antivirals may be considered individually 2
Diabetes Mellitus
Treat identically to general population with corticosteroids within 72 hours: 4
Severity-Based Approach
Incomplete Paralysis (House-Brackmann Grades 1-3)
- Excellent prognosis (up to 94% complete recovery) 2
- Standard corticosteroid therapy 1, 2
- Eye protection as needed 1, 2
- Do NOT perform electrodiagnostic testing 2
Complete Paralysis (House-Brackmann Grades 4-6)
- 70% complete recovery without treatment 2, 4
- Standard corticosteroid therapy 1, 2
- Offer electrodiagnostic testing (ENoG/EMG) at 3-14 days post-onset: 2
- Aggressive eye protection with urgent ophthalmology involvement 2
Mandatory Follow-Up and Referral
Early Follow-Up (1-2 Weeks)
Assess recovery trajectory and reinforce eye protection: 2
- Monitor for early complications 2
- Ensure adequate corneal protection 2
- Identify new neurologic findings 2
3-Month Reassessment: Critical Milestone
Mandatory specialist referral if incomplete recovery at 3 months: 1, 2
- Facial nerve specialist or facial plastic surgeon for reconstructive evaluation 2
- Ophthalmology for persistent eye closure problems 2
- Psychological support for quality of life issues 2
Urgent Referral Triggers (Any Time Point)
Immediate reassessment or specialist referral for: 1, 2
- New or worsening neurologic findings 1, 2
- Development of ocular symptoms 1, 2
- Progressive weakness beyond 3 weeks 2
Therapies NOT Recommended
Do NOT prescribe or recommend: 1, 2
- Antiviral monotherapy (completely ineffective) 1, 2, 3
- Physical therapy (no proven benefit over spontaneous recovery) 1, 2
- Acupuncture (poor quality evidence, indeterminate benefit-harm ratio) 1, 2
- Surgical decompression (rarely indicated except specialized cases) 2
Common Pitfalls to Avoid
Treatment delays: 2
- Corticosteroids lose effectiveness after 72 hours 2
- Never delay treatment for diagnostic testing in typical presentations 1, 2
Inadequate eye protection: 1, 2
- Failure to implement comprehensive eye care leads to permanent corneal damage 1, 2
- Improper eye taping technique can cause corneal abrasion 2
Missed alternative diagnoses: 1, 2
- Failing to test forehead function misses central causes (stroke spares forehead) 1
- Bilateral weakness should never be diagnosed as Bell's palsy 1
- Missing other cranial nerve involvement delays appropriate workup 1
Delayed specialist referral: 2
- Failing to refer at 3 months delays reconstructive options 2
- Facial muscles remain viable re-innervation targets for up to 2 years 6