What is the treatment for recurrent Bell's (Bell's palsy)?

Recurrent Bell's Palsy: Recognition and Management

Yes, Bell's palsy can recur, affecting approximately 7-12% of patients, and recurrent episodes should be managed with the same treatment approach as initial episodes—oral corticosteroids within 72 hours of symptom onset—while maintaining heightened vigilance for atypical features that may suggest alternative diagnoses requiring imaging. 1, 2

Epidemiology of Recurrence

• Recurrent Bell's palsy occurs in 7-12% of all cases, with most patients experiencing only one recurrence 3, 2
• More than two recurrences are uncommon, though cases with up to eleven episodes have been documented in the literature 3
• Recurrence is more likely within the first two years after the initial episode, necessitating close follow-up during this period 2
• Young females appear to have higher rates of recurrent episodes compared to other demographic groups 2
• Recurrences may occur ipsilaterally (same side) or contralaterally (opposite side), with contralateral recurrence being more common in patients with multiple episodes 2

Treatment Approach for Recurrent Episodes

Each recurrent episode should be treated identically to the initial presentation with oral corticosteroids within 72 hours of symptom onset. 1, 4

Primary Treatment Protocol

• Prescribe prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1
• Treatment must be initiated within 72 hours of symptom onset to achieve maximum benefit, as evidence shows 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1
• Combination therapy with oral antivirals (valacyclovir 1 g three times daily for 7 days or acyclovir 400 mg five times daily for 10 days) may be offered alongside corticosteroids, though the added benefit is minimal 1, 4
• Antiviral monotherapy should never be prescribed, as it is ineffective 1, 4

Eye Protection Measures

• Implement immediate eye protection for all patients with impaired eye closure using 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 on proper technique to avoid corneal abrasion 1
• Recommend sunglasses for outdoor protection against wind and foreign particles 1
• Refer urgently to ophthalmology for severe impairment with complete inability to close the eye or signs of corneal exposure 1

Critical Red Flags Requiring Imaging

Recurrent paralysis on the same side (ipsilateral recurrence) is an atypical feature that warrants MRI with and without contrast to exclude tumor or other structural pathology. 1, 5

Indications for Immediate Imaging

• Second episode of paralysis affecting the same side raises concern for tumor, particularly in patients with genetic syndromes like Cowden syndrome 1
• Progressive weakness beyond 3 weeks suggests an alternative diagnosis requiring immediate reassessment 1
• Bilateral facial weakness occurring simultaneously is rare in Bell's palsy and should prompt investigation for Lyme disease, sarcoidosis, or Guillain-Barré syndrome 5, 6
• Isolated branch paralysis (not involving the entire hemifacial distribution) indicates a focal lesion rather than Bell's palsy 1
• Other cranial nerve involvement at any point excludes Bell's palsy and suggests central pathology or skull base tumor 1, 5
• New or worsening neurologic findings beyond facial weakness require urgent evaluation 1

Imaging Protocol When Indicated

• MRI with and without contrast is the imaging test of choice for evaluating recurrent or atypical facial palsy 1, 5
• Dedicated temporal bone CT with thin sections may complement MRI for evaluating bone erosion patterns and surgical planning if tumor is suspected 5

Differential Diagnosis for Recurrent Facial Palsy

Melkersson-Rosenthal Syndrome

• Consider this rare neuromucocutaneous syndrome in patients with recurrent facial paralysis, particularly when accompanied by fissured tongue (lingua plicata) or orofacial edema 2
• This syndrome was identified in 5 of 22 patients (23%) with recurrent facial palsy in one retrospective study 2

Other Causes to Exclude

• Lyme disease should be considered, especially in endemic areas or with bilateral involvement 5, 6
• Sarcoidosis may present with recurrent facial palsy and should be investigated with appropriate laboratory testing 5, 6
• Tumors of the parotid gland, infratemporal fossa, or involving the facial nerve directly must be excluded with imaging 5, 6
• Herpes zoster (Ramsay Hunt syndrome) should be excluded by examining for vesicles in the ear canal or on the face 6

Follow-Up Strategy for Recurrent Cases

• Patients with recurrent Bell's palsy should be followed for at least two years after each episode, as this is the highest-risk period for subsequent recurrence 2
• Mandatory reassessment or specialist referral is required at 3 months if facial recovery is incomplete 1
• Urgent evaluation is needed for new or worsening neurologic findings at any point during the disease course 1
• Development of ocular symptoms at any point necessitates immediate ophthalmology referral 1

Prognosis for Recurrent Episodes

• The prognosis for each recurrent episode is generally similar to the initial episode, with approximately 70% of patients with complete paralysis recovering fully within 6 months and up to 94% of those with incomplete paralysis achieving complete recovery 1, 6
• Children with recurrent Bell's palsy have recovery rates similar to adults, with up to 90% achieving complete recovery 4, 2
• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset, with complete recovery typically occurring within 3-4 months 1

Common Pitfalls to Avoid

• Failing to treat recurrent episodes with corticosteroids based on the assumption that "it will resolve on its own again" delays appropriate therapy and reduces recovery rates 1
• Missing the 72-hour treatment window significantly reduces the effectiveness of corticosteroid therapy 1
• Assuming all recurrences are benign Bell's palsy without considering imaging for ipsilateral recurrence can delay diagnosis of tumor 1, 5
• Neglecting eye protection measures can lead to permanent corneal damage, particularly in patients with severe lagophthalmos 1
• Prescribing antiviral therapy alone without corticosteroids is ineffective and represents inappropriate management 1, 4