Management of Bell's Palsy
Immediate Treatment (Within 72 Hours)
Prescribe oral corticosteroids immediately for all patients 16 years and older presenting within 72 hours of symptom onset 1, 2, 3. This is the only proven effective treatment and significantly improves complete recovery rates from 63.6% to 83.0% at 3 months and from 81.6% to 94.4% at 9 months 4, 5.
Corticosteroid Regimen Options
Choose one of these evidence-based regimens 1, 2, 3:
- Prednisolone 50 mg daily for 10 days 1, 2
- Prednisone 60 mg daily for 5 days, followed by a 5-day taper 1, 3
Critical timing: Treatment must begin within 72 hours of symptom onset—there is no benefit beyond this window 1, 3.
Antiviral Therapy Decision
Do not prescribe antiviral monotherapy—it is completely ineffective 1, 3, 4. This is a strong recommendation against based on high-quality randomized controlled trials 1.
You may optionally add antiviral therapy to corticosteroids within 72 hours 1, 2, though the added benefit is minimal 3, 6. If choosing combination therapy 7:
The evidence shows combination therapy may reduce synkinesis rates but provides only modest additional recovery benefit 7, 6.
Mandatory Eye Protection
Implement aggressive eye protection immediately for all patients with impaired eye closure 1, 2, 3. This is a strong recommendation to prevent permanent corneal damage 1, 2.
Eye Protection Protocol
- Lubricating eye drops every 1-2 hours while awake 2
- Sunglasses outdoors to protect against wind and particles 2, 3
- Ophthalmic ointment at bedtime for sustained moisture 2
- Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 2, 3
- Consider moisture chambers using polyethylene covers for severe cases 2
Urgent ophthalmology referral if 2:
- Complete inability to close the eye
- Signs of corneal exposure or damage (pain, redness, vision changes, discharge)
Initial Diagnostic Assessment
Perform focused history and physical examination to exclude alternative causes 1, 3, 8. Bell's palsy is a diagnosis of exclusion 8.
Key Examination Elements
Assess forehead involvement: Bell's palsy affects the forehead, while stroke spares it 3, 8. This is the critical distinguishing feature 8.
Evaluate facial movement systematically 8:
- Raising eyebrows
- Closing eyes tightly
- Smiling
- Puffing out cheeks
Use House-Brackmann grading scale (Grade 1 = normal to Grade 6 = total paralysis) to document severity 1, 8.
Red Flags Requiring Imaging or Specialist Referral
Do not obtain routine laboratory testing or imaging for typical Bell's palsy 1, 3. However, order MRI with and without contrast if 2, 8:
- Bilateral facial weakness 2, 8
- Isolated branch paralysis 2, 8
- Other cranial nerve involvement 2, 8
- Progressive weakness beyond 3 weeks 2
- Recurrent paralysis on the same side 2, 8
- Slow progression beyond 72 hours 8
- History of head and neck cancer 8
Follow-Up Schedule
Early reassessment at 1-2 weeks to monitor recovery progress, reinforce eye protection, and identify complications 2.
Mandatory reassessment or specialist referral at 3 months if facial recovery is incomplete 1, 2, 3. Approximately 30% of patients may have permanent facial weakness requiring long-term management 2, 8.
Urgent Reassessment Triggers (At Any Time)
Refer immediately to a facial nerve specialist if 1, 2, 3:
- New or worsening neurologic findings at any point
- Development of ocular symptoms at any point
- Progressive weakness beyond expected timeline
Special Populations
Children
Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 2, 3. Children have better prognosis with up to 90% spontaneous recovery 7, but evidence for steroid benefit in pediatrics is less conclusive than in adults 2.
Pregnant Women
Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 2, 3. Eye protection measures are essential and safe in pregnancy 2.
Common Pitfalls to Avoid
Delaying treatment beyond 72 hours eliminates the effectiveness of corticosteroid therapy 3.
Prescribing antiviral monotherapy is completely ineffective and delays appropriate corticosteroid treatment 1, 3, 4.
Inadequate eye protection monitoring can lead to permanent corneal damage, particularly in patients with severe lagophthalmos 2.
Failing to refer at 3 months delays access to reconstructive options and psychological support for patients with incomplete recovery 2.
Missing atypical features such as bilateral weakness, forehead sparing, or other cranial nerve involvement suggests alternative diagnoses requiring different management 2, 3, 8.
Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 3.