Bell's Palsy Management Guidelines
Immediate Treatment: Corticosteroids Within 72 Hours
All patients 16 years and older presenting within 72 hours of symptom onset should receive oral corticosteroids immediately, as this is the only proven effective treatment that significantly improves complete recovery rates. 1, 2
Evidence-Based Corticosteroid Regimens
Choose one of the following regimens 1, 2:
- Prednisolone 50 mg daily for 10 days, OR
- Prednisone 60 mg daily for 5 days, followed by a 5-day taper
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 3, 4. Treatment beyond 72 hours provides no benefit whatsoever 1, 2.
Antiviral Therapy: Limited Role
Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 5
- Antivirals may be added to corticosteroids within 72 hours, but the added benefit is minimal 1, 2, 4
- If using combination therapy, consider acyclovir 400 mg orally five times daily for 10 days or valacyclovir at standard dosing 3
- The 2012 American Academy of Neurology review concluded that adding antivirals to steroids may increase recovery likelihood only by a very modest effect 5
Mandatory Eye Protection for All Patients
Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage. 1, 2
Daytime Protection
- Lubricating eye drops every 1-2 hours while awake 1, 2
- Sunglasses outdoors to protect against wind and particles 1, 2
Nighttime Protection
- Ophthalmic ointment at bedtime for sustained moisture 1, 2
- Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
- Consider moisture chambers using polyethylene covers for severe cases 3
Urgent Ophthalmology Referral Indications
- Severe impairment with complete inability to close the eye 3
- Eye pain, vision changes, redness, discharge, or foreign body sensation 3
- Persistent lagophthalmos beyond 3 months may require tarsorrhaphy or eyelid weight implantation 3, 6
Diagnostic Assessment: Exclude Alternative Causes
Bell's palsy is a diagnosis of exclusion requiring focused history and physical examination to rule out other causes of facial weakness. 1, 2
Key Examination Features
- Forehead involvement distinguishes Bell's palsy from stroke (stroke spares the forehead) 2, 3
- Document severity using the House-Brackmann grading scale (grades 1-6) 1, 3
- Assess all facial movements: raising eyebrows, closing eyes tightly, smiling, puffing cheeks 3
- Verify acute onset over 24-72 hours 2, 3
Red Flags Requiring MRI with and Without Contrast
- Bilateral facial weakness 1, 2, 3
- Isolated branch paralysis 1, 3
- Other cranial nerve involvement 1, 2, 3
- Recurrent paralysis on the same side 3
- Progressive weakness beyond 3 weeks 3
- No recovery after 3 months 1, 3
Do not order routine laboratory testing or imaging for typical Bell's palsy presentations—this increases costs without benefit. 1, 2, 3
Follow-Up Schedule
Early Reassessment (1-2 Weeks)
- Monitor recovery progress 1
- Reinforce eye protection measures 1
- Identify complications or new neurologic findings 3
Mandatory Reassessment at 3 Months
All patients with incomplete facial recovery at 3 months must be reassessed or referred to a facial nerve specialist. 1, 2, 3
Approximately 30% of patients may have permanent facial weakness requiring long-term management including 1, 3:
- Reconstructive surgery options (static procedures like eyelid weights, brow lifts, facial slings; dynamic procedures like nerve transfers) 3
- Continued ophthalmology care for persistent eye closure problems 3
- Psychological support for quality of life issues, depression screening, and social isolation 3, 6
Urgent Reassessment Triggers (At Any Time)
- New or worsening neurologic findings 2, 3
- Development of ocular symptoms 2, 3
- Progressive weakness beyond expected recovery timeline 3
Special Populations
Children
- Children have better prognosis with up to 90% spontaneous recovery 1, 3
- Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, as pediatric-specific evidence is limited 1, 3
- Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper if treating 3
- Same 72-hour treatment window and eye protection measures apply 3
Pregnant Women
- Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 3
- Eye protection measures are essential and safe in pregnancy 1, 3
- Combination therapy with antivirals may be considered on an individualized basis 3
Prognosis and Natural History
Recovery Rates by Severity
- Incomplete paralysis: up to 94% complete recovery 1, 3
- Complete paralysis: approximately 70% complete recovery within 6 months 1, 3
- Most patients begin showing recovery within 2-3 weeks 1, 3
- Complete recovery typically occurs within 3-4 months 3
Prognostic Factors
- Incomplete paralysis at presentation predicts faster and more complete recovery 3
- Electrodiagnostic testing showing >10% nerve response amplitude indicates excellent prognosis 3
- Complete paralysis with <10% function carries up to 50% risk of incomplete recovery 3
Therapies NOT Recommended
Do not offer the following interventions, as they have no proven benefit or insufficient evidence: 1, 3
- Physical therapy 1, 3
- Acupuncture 1, 3
- Surgical decompression (except rare specialized cases) 3
- Electrodiagnostic testing for incomplete paralysis 1
Critical Pitfalls to Avoid
- Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 2
- Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2
- Inadequate eye protection monitoring can lead to permanent corneal damage, particularly with severe lagophthalmos 1, 3
- Failing to refer at 3 months delays access to reconstructive options and psychological support 1, 3
- Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 2, 3
- Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2, 3
- Improper eye taping technique can cause corneal abrasion—patients must be carefully instructed 3
- Neglecting psychological impact can exacerbate depression and social isolation in patients with persistent facial asymmetry 3, 6