What is the recommended treatment for an adult patient with no underlying medical conditions diagnosed with Bell's palsy?

Treatment of Bell's Palsy in Adults

Prescribe oral corticosteroids within 72 hours of symptom onset—specifically 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 corticosteroids immediately upon diagnosis for patients 16 years and older, as treatment effectiveness diminishes rapidly after the 72-hour window 1
• The evidence is compelling: 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
• Two acceptable regimens exist:
  • Prednisolone 50 mg orally daily for 10 days 1
  • Prednisone 60 mg orally daily for 5 days, then taper over 5 days 1, 2

Antiviral Therapy Considerations

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 3
• You may offer combination therapy (corticosteroids plus antivirals) within 72 hours, though the added benefit is minimal 1, 2
• If choosing combination therapy, use valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 1, 2
• The decision to add antivirals should acknowledge that while complete recovery rates may increase slightly (96.5% versus 89.7% with steroids alone), the benefit is small and corticosteroids remain the cornerstone 1

Critical Eye Protection Protocol

Immediate Implementation

Implement comprehensive eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage. 1

Daytime Protection

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1
• Use sunglasses outdoors to protect against wind and foreign particles 1
• Consider moisture chambers using polyethylene covers for severe cases 1

Nighttime Protection

• Apply ophthalmic ointment at bedtime for sustained moisture retention 1
• Use eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
• Critical pitfall: Improper taping technique can cause corneal abrasion—demonstrate the technique and have the patient practice 1

Urgent Ophthalmology Referral Triggers

• Severe impairment with complete inability to close the eye 1
• Any signs of corneal exposure or damage (eye pain, vision changes, redness, discharge, foreign body sensation) 1
• Persistent lagophthalmos beyond 3 months 1

Diagnostic Testing: What NOT to Do

• Do not order routine laboratory tests—they are not recommended for typical Bell's palsy 1, 4
• Do not order diagnostic imaging for straightforward presentations 1, 4
• Electrodiagnostic testing (ENoG, EMG) may be offered only for 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

Mandatory Follow-Up and Referral Triggers

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

Immediate Reassessment Required For:

• New or worsening neurologic findings at any point (suggests alternative diagnosis like stroke, tumor, or CNS pathology) 1, 4
• Development of ocular symptoms at any point 1, 4
• Progressive weakness beyond 3 weeks (major red flag for alternative diagnosis) 1

Early Follow-Up Schedule

• Initial visit within 72 hours for treatment initiation and eye care education 1
• Follow-up at 1-2 weeks to assess recovery trajectory, reinforce eye protection, and identify early complications 1
• Most patients begin showing recovery within 2-3 weeks 1, 4

Red Flags Requiring Imaging

Order MRI with and without contrast if any of these features are present 1, 5:

• Recurrent paralysis on the same side 1
• Isolated branch paralysis (not diffuse facial nerve involvement) 1, 5
• Other cranial nerve involvement 1, 5
• Bilateral facial weakness 5, 4
• No recovery after 3 months 1, 5
• Progressive weakness beyond expected timeline 1

Therapies to AVOID

Not Recommended

• Physical therapy: No proven benefit over spontaneous recovery 1, 3
• Acupuncture: Poor-quality trials with indeterminate benefit-harm ratio 1
• Surgical decompression: Rarely indicated except in specialized circumstances 1

Prognosis Counseling

Expected Recovery Rates

• Patients with incomplete paralysis: up to 94% complete recovery 1, 4
• Patients with complete paralysis: approximately 70% complete recovery within 6 months 1, 4
• Most patients begin recovery within 2-3 weeks, with complete recovery typically by 3-4 months 1, 4

Long-Term Complications

• Approximately 30% may experience permanent facial weakness with muscle contractures 1, 4
• Potential complications include lacrimal dysfunction, nasal airway obstruction, oral incompetence, and significant psychosocial impact 1
• Screen for depression in patients with persistent paralysis and refer when needed 1

Common Clinical Pitfalls

• Delaying corticosteroids beyond 72 hours: Treatment effectiveness drops significantly 1
• Prescribing antivirals alone: Completely ineffective and delays appropriate treatment 1, 3
• Inadequate eye protection monitoring: Can lead to permanent corneal damage 1
• Failing to refer at 3 months: Delays access to reconstructive options and psychological support 1
• Missing atypical features: Bilateral weakness, isolated branch paralysis, or other cranial nerve involvement suggest alternative diagnoses requiring different management 1, 5
• Underdosing steroids: Using a standard methylprednisolone dose pack provides only 105 mg prednisone equivalent versus 540 mg over 14 days with proper dosing 1