What is the recommended management for an adult patient presenting with Bell's palsy?

Management of Bell's Palsy

Oral corticosteroids within 72 hours of symptom onset combined with aggressive eye protection are the cornerstones of Bell's palsy management for patients 16 years and older. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, perform a focused examination to exclude alternative causes of facial weakness:

• Assess forehead involvement – Bell's palsy affects the forehead (distinguishing it from stroke, which spares forehead function) 3, 2
• Rule out trauma – temporal bone fracture or surgical injury 3, 2
• Exclude infection, tumor, or stroke – look for bilateral weakness, isolated branch paralysis, or other cranial nerve involvement 3, 2
• Verify acute onset – symptoms should develop over 24-72 hours 1, 3
• Do NOT order routine laboratory testing or imaging for typical presentations 1, 3, 2

Primary Treatment: Corticosteroids (MUST START WITHIN 72 HOURS)

Treatment initiated after 72 hours provides minimal benefit and should generally be avoided. 4, 2

Recommended Regimens (choose one):

• Prednisolone 50 mg daily for 10 days 1, 3, 2
• Prednisone 60 mg daily for 5 days, followed by 5-day taper 1, 3, 2

Evidence Supporting Corticosteroids:

• 83% complete recovery at 3 months with prednisolone vs 63.6% with placebo 1, 3, 5
• 94.4% complete recovery at 9 months with prednisolone vs 81.6% with placebo 1, 3, 5

The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation for corticosteroids based on high-quality randomized controlled trials. 1, 2

Antiviral Therapy: Limited Role

Never prescribe antiviral monotherapy alone – it is completely ineffective. 1, 2, 5

Optional Combination Therapy:

You may offer antivirals in addition to corticosteroids within 72 hours, though the added benefit is minimal: 1, 2

• Valacyclovir 1 g three times daily for 7 days 6
• Acyclovir 400 mg five times daily for 10 days 3, 6

The 2007 landmark trial showed no benefit of acyclovir alone (71.2% recovery vs 75.7% without acyclovir, P=0.50) and no additional benefit when combined with prednisolone. 5 The American Academy of Neurology concluded that if antivirals provide any benefit at all, it is "very modest." 7

Eye Protection: MANDATORY for All Patients with Impaired Eye Closure

Inadequate eye protection can lead to permanent corneal damage. 4, 2

Implement the following measures immediately:

Daytime protection:

• Lubricating eye drops every 1-2 hours while awake 3, 2
• Sunglasses outdoors to protect against wind and foreign particles 3, 2

Nighttime protection:

• Ophthalmic ointment at bedtime for sustained moisture retention 4, 3, 2
• Eye taping or patching with careful instruction to avoid corneal abrasion 4, 3, 2
• Moisture chambers using polyethylene covers for severe cases 4, 3

Urgent ophthalmology referral if:

• Complete inability to close the eye 3
• Eye pain, vision changes, redness, or discharge 4
• Signs of corneal exposure or damage 3

Follow-Up and Reassessment

Routine Follow-Up:

• Early reassessment at 1-2 weeks to monitor recovery, reinforce eye protection, and identify complications 3
• Mandatory reassessment at 3 months for all patients with incomplete recovery 1, 4, 3, 2

Urgent Reassessment Triggers (at any time):

Refer immediately to a facial nerve specialist if: 1, 4, 3, 2

• New or worsening neurologic findings
• Development of ocular symptoms
• Progressive weakness beyond 3 weeks
• Bilateral facial weakness
• Isolated branch paralysis
• Other cranial nerve involvement

Red Flags Requiring Imaging (MRI with and without contrast):

• Recurrent paralysis on the same side 3
• No recovery after 3 months 1, 3
• Atypical features suggesting tumor or other pathology 1, 3

Special Populations

Children:

• Better prognosis than adults with up to 90-94% complete recovery rates 3, 6
• May consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 3, 2
• Evidence for steroid benefit in children is less conclusive than in adults 3

Pregnant Women:

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 3, 2
• Eye protection measures are essential and safe in pregnancy 3

Prognosis and Natural History

Understanding natural history helps set realistic patient expectations:

• Incomplete paralysis: up to 94% complete recovery 1, 3, 2
• Complete paralysis: approximately 70% complete recovery within 6 months 1, 4, 3
• Most patients begin showing recovery within 2-3 weeks 4, 3
• 30% may experience permanent facial weakness with muscle contractures 4, 3

Long-Term Management for Incomplete Recovery at 3 Months

Refer to facial nerve specialist or facial plastic surgeon for: 4, 3

• Evaluation of reconstructive procedures (static or dynamic facial slings, nerve transfers)
• Persistent eye closure problems requiring tarsorrhaphy or eyelid weight implantation
• Psychological support for quality of life issues and depression screening

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours – dramatically reduces effectiveness 4, 2
• Using antiviral monotherapy – completely ineffective and delays appropriate corticosteroid treatment 1, 2, 5
• Inadequate eye protection – can lead to permanent corneal damage 4, 2
• Failing to refer at 3 months – delays access to reconstructive options 4, 3
• Missing atypical features – bilateral weakness, forehead sparing, or other cranial nerve involvement suggests alternative diagnoses 3, 2
• Ordering routine labs or imaging – unnecessary for typical presentations and increases costs without benefit 1, 3, 2
• Underdosing steroids – using a standard methylprednisolone dose pack provides only 105 mg prednisone equivalent vs 540 mg over 14 days with proper dosing 3

Therapies NOT Recommended

• Physical therapy – no proven benefit over spontaneous recovery 3, 7
• Acupuncture – poor-quality trials with indeterminate benefit-harm ratio 1, 3
• Surgical decompression – rarely indicated except in specialized cases 1, 3
• Electrodiagnostic testing for incomplete paralysis – not recommended 1