What is the recommended treatment for a patient with Bell's palsy who has completed a course of steroids and antivirals 3 days ago and is showing daily improvement?

Ongoing Management for Improving Bell's Palsy After Completing Steroids and Antivirals

For a patient with Bell's palsy who completed steroids and antivirals 3 days ago and is showing daily improvement, continue aggressive eye protection measures, provide reassurance about the favorable prognosis, and schedule follow-up at 1-2 weeks to monitor recovery trajectory and reinforce eye care. 1, 2

Immediate Ongoing Care

Eye Protection (Mandatory)

Even with improving facial function, continue comprehensive eye protection until complete eye closure is restored 1, 2:

Daytime measures:

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Wear sunglasses outdoors to protect against wind and foreign particles 1, 2

Nighttime measures:

• Apply ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Use eye taping or patching with proper technique to avoid corneal abrasion 1, 2
• Consider moisture chambers using polyethylene covers for severe cases 1

Monitoring for Red Flags

Instruct the patient to seek immediate medical attention if any of the following develop 1, 2:

• New or worsening neurologic findings at any point 3, 1, 2
• Development of ocular symptoms (eye pain, vision changes, redness, discharge, foreign body sensation, or increasing irritation despite protection measures) 1
• Progressive weakness beyond 3 weeks from onset 1

Expected Recovery Timeline

Reassure the patient about favorable prognosis: Most patients begin showing signs of recovery within 2-3 weeks of symptom onset, with complete recovery typically occurring within 3-4 months 1, 4. Since this patient is already improving daily, the prognosis is excellent 1.

For patients with incomplete paralysis at presentation (which appears to be this patient's case given daily improvement), recovery rates reach up to 94% 1, 4. This is significantly better than the 70% recovery rate for patients with complete paralysis 1.

Follow-Up Schedule

Schedule early reassessment at 1-2 weeks after the initial presentation to 1, 2:

• Monitor recovery progress and document improvement using the House-Brackmann grading scale 1, 2
• Reinforce eye protection techniques and ensure compliance 1, 2
• Identify any early complications or atypical features 1, 2

Mandatory reassessment or specialist referral at 3 months if facial recovery remains incomplete 3, 1, 2. Approximately 30% of patients may experience permanent facial weakness requiring long-term management including reconstructive procedures, ophthalmology referral for persistent eye closure problems, and psychological support 1.

What NOT to Do

Do not prescribe additional treatments such as 3, 1, 2:

• Physical therapy (no proven benefit over spontaneous recovery) 3, 1
• Acupuncture (insufficient evidence, no recommendation can be made) 3, 1
• Additional antiviral or steroid courses (no evidence for benefit beyond initial 72-hour window) 3, 1, 2, 4

Do not order routine imaging or laboratory testing for this typical presentation with improving symptoms 3, 1, 2. Imaging with MRI (with and without contrast) is only indicated for atypical features such as bilateral weakness, isolated branch paralysis, other cranial nerve involvement, or no recovery after 3 months 3, 1, 2.

Common Pitfalls to Avoid

• Inadequate eye protection monitoring can lead to permanent corneal damage, particularly in patients with severe lagophthalmos 1, 2
• Failing to refer at 3 months if recovery is incomplete delays access to reconstructive options and psychological support 1, 2
• Missing atypical features such as progressive weakness beyond 3 weeks, which suggests alternative diagnoses requiring different management 1
• Neglecting psychological impact in patients with persistent facial asymmetry can exacerbate depression and social isolation 1