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

Bell's Palsy Initial Management

Start 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 complete recovery rates from 63.6% to 83% at 3 months. 1, 2, 3, 4

Immediate Treatment Algorithm (Within 72 Hours)

Corticosteroid Therapy (Mandatory)

• Initiate treatment within 72 hours of symptom onset—no benefit exists beyond this window 1, 2
• Dosing options: 1, 2
  • Prednisolone 50 mg orally daily for 10 days, OR
  • Prednisone 60 mg orally daily for 5 days, then taper over 5 days
• Evidence: Recovery improves to 94.4% at 9 months with prednisolone versus 81.6% without treatment 1, 3, 4
• Number needed to treat: 6 patients to achieve one additional complete recovery 3

Antiviral Therapy (Optional, Minimal Benefit)

• Never prescribe antivirals alone—completely ineffective as monotherapy 1, 2, 5
• May add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours 1, 5
• Added benefit is minimal: combination therapy shows 96.5% recovery versus 89.7% with steroids alone, but this small benefit comes with minimal risk 1

Mandatory Eye Protection (Start Immediately)

Daytime Measures

• Lubricating eye drops every 1-2 hours while awake to prevent corneal drying 1, 2
• Sunglasses outdoors to protect against wind and foreign particles 1, 2

Nighttime Measures

• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Moisture chambers using polyethylene covers for severe cases 1

Urgent Ophthalmology Referral If:

• Complete inability to close the eye 1
• Signs of corneal exposure or damage (pain, redness, vision changes) 1

Initial Diagnostic Assessment

Clinical Diagnosis (No Routine Testing)

• Confirm unilateral facial weakness involving the forehead (distinguishes from stroke, which spares forehead) 1, 6, 7
• Document severity using House-Brackmann grading scale (1=normal to 6=total paralysis) 1, 6
• Verify symptom onset within 72 hours 1, 6
• Do NOT order routine labs or imaging for typical presentations 1, 2

Red Flags Requiring MRI with and without Contrast

• Bilateral facial weakness 1, 2, 6
• Isolated branch paralysis (not entire facial nerve distribution) 1, 2
• Other cranial nerve involvement 1, 2
• Recurrent paralysis on the same side 1
• Progressive weakness beyond 3 weeks 1
• History of head and neck cancer 6
• Forehead sparing (suggests central lesion like stroke) 1

Follow-Up Schedule

Early Reassessment (1-2 Weeks)

• Monitor recovery progress and ensure adequate eye protection 2
• Identify early complications or new neurologic findings 2

Mandatory 3-Month Reassessment

• Refer to facial nerve specialist if incomplete recovery at 3 months, as 30% may have permanent weakness requiring reconstructive options 1, 2, 6
• Refer immediately at any time if: 1, 2
  • New or worsening neurologic findings develop
  • Ocular symptoms emerge (pain, vision changes, redness)
  • Progressive weakness beyond expected timeline

Special Populations

Children

• Better prognosis: up to 90% spontaneous recovery 2, 5
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, though pediatric evidence is less conclusive 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2
• Eye protection measures are essential and safe in pregnancy 1, 2

Critical Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 2
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 5
• Inadequate eye protection monitoring leads to permanent corneal damage, particularly with severe lagophthalmos 1, 2
• Failing to refer at 3 months delays reconstructive options and psychological support 1, 2
• Missing forehead sparing suggests stroke, not Bell's palsy 1, 7
• Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2

Therapies NOT Recommended

• Physical therapy: no proven benefit over spontaneous recovery 1, 2
• Acupuncture: poor-quality trials, no recommendation possible 1, 2
• Surgical decompression: rarely indicated except in specialized trauma cases 1, 2
• Electrodiagnostic testing: not recommended for incomplete paralysis 1, 2