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

Bell's Palsy Treatment

First-Line Treatment: Oral Corticosteroids

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy—this is the only proven effective treatment and significantly improves facial nerve recovery. 1

Recommended Corticosteroid Regimens

• Prednisolone 50 mg daily for 10 days (preferred regimen) 1
• OR Prednisone 60 mg daily for 5 days, followed by a 5-day taper (10 mg reduction daily) 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
• Patients with incomplete paralysis have recovery rates up to 94%, while those with complete paralysis recover in approximately 70% of cases 1

Critical Timing Consideration

Do not initiate corticosteroids beyond 72 hours of symptom onset—there is no evidence of benefit after this window, and treatment effectiveness decreases significantly with delay. 1

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Antiviral Therapy: Optional Adjunct Only

Strong Recommendation Against Monotherapy

Never prescribe antiviral therapy alone for Bell's palsy—it is completely ineffective as monotherapy. 1, 2

Combination Therapy: Minimal Benefit

• Combination therapy with antivirals plus corticosteroids may be offered (not recommended) within 72 hours as an optional adjunct 1
• The added benefit is small: 96.5% complete recovery with combination therapy versus 89.7% with steroids alone 1
• Some evidence suggests combination therapy may reduce synkinesis rates (involuntary co-contraction of facial muscles) 2

Antiviral Dosing (If Used)

• Valacyclovir 1 g three times daily for 7 days 2
• OR Acyclovir 400 mg five times daily for 10 days 1, 2

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Mandatory Eye Protection

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent corneal damage—this is a critical component of management. 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 during the disease course 1

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Diagnostic Approach

Clinical Diagnosis

• Bell's palsy is diagnosed clinically based on acute unilateral facial weakness involving the forehead, with onset in less than 72 hours 1, 2
• Routine laboratory testing and diagnostic imaging are NOT recommended for initial diagnosis 1

Red Flags Requiring Imaging

Order MRI with and without contrast immediately if any of the following are present: 1

• Recurrent paralysis on the same side (concern for tumor) 1, 3
• Bilateral facial weakness (rare in Bell's palsy; suggests alternative diagnosis) 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1

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Follow-Up and Reassessment

Mandatory 3-Month Reassessment

Refer all patients with incomplete facial recovery at 3 months to a facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options. 1, 4

Urgent Reassessment Triggers (At Any Time)

• New or worsening neurologic findings 1, 4
• Development of ocular symptoms 1, 4
• Progressive weakness beyond expected recovery timeline 1

Expected Recovery Timeline

• 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

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Special Populations

Pediatric Patients

• Children have better prognosis with higher spontaneous recovery rates (up to 90%) 2
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider oral corticosteroids on an individualized basis with substantial caregiver participation in shared decision-making 1
• Dosing: Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by 5-day taper 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using the same regimens as non-pregnant adults 1
• Careful individualized assessment of benefits and risks is required 1
• Eye protection measures are essential and safe in pregnancy 1

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Therapies NOT Recommended

No Evidence of Benefit

• Physical therapy: No proven benefit over spontaneous recovery, though may be considered for severe paralysis with developing synkinesis 1, 4, 2
• Acupuncture: No recommendation can be made due to poor-quality trials 1
• Surgical decompression: Rarely indicated except in specialized cases (e.g., traumatic facial nerve palsy with >90% amplitude reduction on electrodiagnostic testing) 1

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Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness dramatically 1
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate corticosteroid treatment 1, 2
• Using standard methylprednisolone dose packs provides only 105 mg prednisone equivalent versus 540 mg over 14 days with proper dosing—this represents significant underdosing 1
• Failing to provide adequate eye protection can lead to permanent corneal damage 1
• Missing atypical features (bilateral weakness, recurrence, other cranial nerve involvement) that require imaging and specialist referral 1, 3
• Failing to refer at 3 months for incomplete recovery delays access to reconstructive options and psychological support 1