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

Treatment of Bell's Palsy

Prescribe oral corticosteroids within 72 hours of symptom onset—prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper—as this is the only proven effective treatment that significantly improves facial nerve recovery. 1

Immediate Management (Within 72 Hours)

Corticosteroid Therapy

• Start prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days with 5-day taper for patients 16 years and older 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
• Treatment beyond 72 hours has no proven benefit and should not be initiated 1
• For children, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper, though pediatric evidence is less conclusive than adult data 1

Antiviral Therapy Considerations

• Never prescribe antiviral monotherapy—it is completely ineffective 1, 2
• May offer valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days in combination with corticosteroids 1, 2
• The added benefit is minimal (96.5% complete recovery with combination versus 89.7% with steroids alone), but risks are low 1
• Combination therapy may reduce synkinesis rates (involuntary co-contraction of facial muscles from misdirected nerve fiber regrowth) 2

Eye Protection (Critical for All Patients)

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1
• Apply ophthalmic ointment at bedtime for sustained moisture retention 1
• Use eye taping or patching at night with careful instruction to avoid corneal abrasion 1
• Recommend sunglasses outdoors to protect against wind and foreign particles 1
• Consider moisture chambers using polyethylene covers for severe cases 1
• Refer urgently to ophthalmology if complete inability to close eye or signs of corneal exposure develop 1

Diagnostic Approach

Clinical Diagnosis

• Diagnose Bell's palsy based on acute onset (<72 hours) of unilateral facial weakness involving the forehead, with no identifiable cause 1, 3
• Perform thorough history and physical examination to exclude stroke (forehead sparing, other neurologic deficits), trauma, infection (Lyme disease, herpes zoster), tumor, or sarcoidosis 1, 3
• Document function of all cranial nerves to exclude central causes 3

Testing NOT Recommended

• Do not order routine laboratory tests or imaging for typical Bell's palsy presentations 1
• Electrodiagnostic testing (ENoG, EMG) should only be offered to patients with complete facial paralysis, performed 3-14 days post-onset 1
• Testing before 7 days or after 14-21 days provides unreliable prognostic information due to ongoing Wallerian degeneration 1

When to Order MRI

• Order MRI with and without contrast for atypical features: recurrent paralysis on same side, isolated branch paralysis, other cranial nerve involvement, progressive weakness beyond 3 weeks, or no recovery after 3 months 1, 3

Follow-Up and Referral

Mandatory Reassessment Points

• Refer to facial nerve specialist at 3 months if incomplete facial recovery 1
• Refer immediately for new or worsening neurologic findings at any point (suggests alternative diagnosis like stroke or tumor) 1
• Refer immediately for ocular symptoms developing at any point (risk of permanent corneal damage) 1

Expected Recovery Timeline

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

Special Populations

Pregnant Women

• Treat with oral corticosteroids within 72 hours using same regimen as non-pregnant patients 1
• Eye protection measures are essential and safe in pregnancy 1
• Consider combination therapy with antivirals on individualized basis 1

Children

• Children have better prognosis than adults with higher spontaneous recovery rates (up to 90%) 1, 2
• Benefit of corticosteroid treatment in children is inconclusive, but may consider for severe or complete paralysis 1
• Involve caregivers in shared decision-making given uncertain benefit-harm ratio 1

Therapies NOT Recommended

Ineffective Treatments

• Physical therapy has no proven benefit over spontaneous recovery—do not recommend 1
• Acupuncture has poor-quality evidence with indeterminate benefit-harm ratio—do not recommend 1
• Surgical decompression is rarely indicated except in specialized centers for specific traumatic cases 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates effectiveness 1
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1
• Failing to provide adequate eye protection can lead to permanent corneal damage 1
• Missing atypical features (bilateral weakness, isolated branch paralysis, other cranial nerve involvement, progressive weakness beyond 3 weeks) that indicate alternative diagnoses requiring imaging 1, 3
• Failing to refer at 3 months for incomplete recovery delays access to reconstructive options 1
• Underdosing steroids—standard methylprednisolone dose pack provides only 105 mg prednisone equivalent versus 540 mg needed over 14 days 1