Treatment of Bell's Palsy
Primary Treatment: Corticosteroids Within 72 Hours
All patients 16 years and older with Bell's palsy should receive oral corticosteroids within 72 hours of symptom onset—this is the only proven effective treatment and significantly improves facial nerve recovery. 1, 2
Recommended Corticosteroid Regimens
Choose one of these evidence-based options:
- Prednisolone 50 mg daily for 10 days 1, 2
- Prednisone 60 mg daily for 5 days, followed by a 5-day taper 1, 2
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 2. Treatment beyond 72 hours provides no benefit 1.
Critical Timing Consideration
Do not delay treatment beyond 72 hours—effectiveness drops dramatically after this window. 1 This is the single most important pitfall to avoid in Bell's palsy management.
Antiviral Therapy: Limited and Controversial Role
Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2
You may offer antivirals in addition to corticosteroids within 72 hours, though the added benefit is minimal 1, 2. If choosing combination therapy:
One older study showed combination therapy may reduce synkinesis rates 3, and another demonstrated 96.5% complete recovery with combination versus 89.7% with steroids alone 2. However, current guidelines classify this as optional rather than recommended 1.
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
Eye Protection Protocol
Daytime measures:
- Lubricating eye drops every 1-2 hours while awake 1, 2
- Sunglasses outdoors for protection against wind and particles 1, 2
Nighttime measures:
- 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 1
Warning: Improper eye taping can cause corneal abrasion—patients must receive careful instruction 1. Inadequate eye protection can lead to permanent corneal damage 1.
When to Refer to Ophthalmology
Urgent ophthalmology referral is required for:
- Severe impairment with complete inability to close the eye 1
- Eye pain, vision changes, redness, or discharge 1
- Signs of corneal exposure or damage 1
Initial Diagnostic Assessment
Before diagnosing Bell's palsy, perform a focused history and physical examination to exclude alternative causes 1, 2:
Key Distinguishing Features
Forehead involvement is crucial: Bell's palsy affects the forehead, while stroke spares it 1. This is the most important clinical distinction.
Red Flags Requiring Further Investigation
Do not diagnose Bell's palsy if any of these are present:
- Bilateral facial weakness 1
- Isolated branch paralysis 1
- Other cranial nerve involvement 1
- Forehead sparing (suggests stroke) 1
- Gradual onset beyond 72 hours 1
- Recurrent paralysis on the same side 2
- Progressive weakness beyond 3 weeks 2
Imaging and Laboratory Testing
Routine labs and imaging are NOT recommended for typical Bell's palsy presentations. 2 This increases costs without benefit 1.
Order MRI with and without contrast only for:
Special Populations
Children
Children have better prognosis than adults with higher spontaneous recovery rates (up to 90%) 3. Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, but understand that pediatric evidence is weaker than adult data. 1, 2
Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper if treating 1.
Pregnant Women
Treat pregnant women with oral corticosteroids within 72 hours using individualized risk-benefit assessment. 1, 2 Eye protection measures are essential and safe in pregnancy 2.
Follow-Up and Referral Criteria
Mandatory 3-Month Assessment
Refer to a facial nerve specialist if facial recovery is incomplete at 3 months. 1, 2 Failing to refer at this point delays access to reconstructive options 1.
Urgent Reassessment Triggers (At Any Time)
Immediate reassessment or specialist referral is required for:
- New or worsening neurologic findings 1, 2
- Development of ocular symptoms 1, 2
- Progressive weakness beyond expected timeline 2
Early Follow-Up Recommendations
Schedule follow-up at 1-2 weeks to:
Prognosis and Natural History
Understanding prognosis helps set realistic patient expectations:
Incomplete paralysis at presentation: Up to 94% complete recovery 1, 2
Complete paralysis: Approximately 70% complete recovery within 6 months 1, 2
Most patients begin showing recovery within 2-3 weeks 1. However, 30% may experience permanent facial weakness with muscle contractures 1, 2.
Treatments NOT Recommended
Do not offer these interventions:
- Antiviral monotherapy (completely ineffective) 1, 2
- Physical therapy (no proven benefit over spontaneous recovery) 2
- Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 2
- Surgical decompression (rarely indicated except in specialized cases) 2
Long-Term Management for Incomplete Recovery
For patients with persistent deficits beyond 3 months, multidisciplinary management addresses:
Functional complications:
- Persistent lagophthalmos requiring ophthalmology referral for tarsorrhaphy or eyelid weight implantation 1, 2
- Lacrimal dysfunction (dry eye) 1
- Nasal airway obstruction 1
- Oral incompetence affecting eating, drinking, and speaking 1
Reconstructive options:
- Static procedures: eyelid weights, brow lifts, static facial slings 1
- Dynamic procedures: nerve transfers, dynamic facial slings 1
Psychological support: