How should acute Bell’s palsy be managed, including timing of treatment, use of corticosteroids and antivirals, eye protection, facial exercises, follow‑up, and indications for further investigation or surgery?

Management of Bell's Palsy

Immediate Treatment (Within 72 Hours of Onset)

Start oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—this is the only intervention proven to improve facial nerve recovery. 1, 2, 3

Corticosteroid Regimen

Choose one of these evidence-based regimens:

• Prednisolone 50 mg once daily for 10 days, OR 1, 2, 3
• Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily over the next 5 days 1, 2, 3

The evidence is compelling: 83% of patients recover completely at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recover at 9 months versus 81.6% with placebo. 1, 2 Do not initiate corticosteroids after 72 hours—there is no evidence of benefit beyond this window and you expose patients to medication risks without therapeutic gain. 1, 2

For patients with diabetes, corticosteroids remain strongly indicated despite temporary hyperglycemia risk—monitor capillary glucose every 2-4 hours during the first few days and proactively adjust insulin or oral hypoglycemic agents. 2 The therapeutic benefit outweighs the metabolic risk. 2

Antiviral Therapy

Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate treatment. 1, 2, 3 You may offer valaciclovir 1000 mg three times daily for 7 days (or aciclovir 400 mg five times daily for 10 days) in addition to corticosteroids within 72 hours, but the added benefit is minimal. 2, 4 The landmark trial by Sullivan et al. showed no difference in recovery time with valaciclovir (hazard ratio 1.01, p=0.90). 4

Eye Protection (Mandatory for All Patients with Impaired Eye Closure)

Implement aggressive eye protection immediately to prevent corneal damage—this is non-negotiable for any patient who cannot fully close the affected eye. 1, 2, 3

Daytime Protection

• Lubricating eye drops (e.g., hydroxypropyl methylcellulose) every 1-2 hours while awake 1, 2
• Sunglasses outdoors to protect against wind, debris, and UV exposure 1, 2

Nighttime Protection

• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Moisture chambers using polyethylene covers for severe cases 1, 2

Urgent Ophthalmology Referral Triggers

Refer immediately if the patient develops:

• Eye pain, vision changes, or increasing redness 1
• Sensation of foreign body or discharge 1
• Complete inability to close the eye 2
• Signs of corneal exposure or damage 2

Diagnostic Assessment

Do not order routine laboratory tests or imaging for typical Bell's palsy—they delay treatment without improving outcomes. 2, 3 Diagnosis is clinical, based on:

• Acute onset of unilateral facial weakness developing over 24-72 hours 2, 3
• Involvement of the forehead (distinguishes from stroke, which spares the forehead) 2, 3
• No identifiable cause after focused history and physical examination 2, 3

Red Flags Requiring Imaging (MRI with and without contrast)

Order imaging if you identify:

• Bilateral facial weakness 2, 3
• Isolated branch paralysis (e.g., only lower face affected) 2
• Other cranial nerve involvement 2
• Recurrent paralysis on the same side 2
• Progressive weakness beyond 3 weeks 2
• No sign of recovery after 3 months 1, 2

Electrodiagnostic Testing

Do not perform electrodiagnostic testing for incomplete facial paralysis. 2 For complete paralysis, you may offer testing between 3-14 days post-onset to assess prognosis: >10% nerve response amplitude predicts excellent recovery, while <10% indicates up to 50% risk of incomplete recovery. 2

Follow-Up Schedule

Early Follow-Up (1-2 Weeks)

Schedule within 1-2 weeks to:

• Assess recovery trajectory (most patients begin showing improvement within 2-3 weeks) 1, 2
• Reinforce eye protection techniques 1
• Identify early complications or new neurologic findings 2

Mandatory 3-Month Reassessment

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months—this is mandatory, not optional. 1, 2, 3 Approximately 30% of patients with complete paralysis may experience permanent facial weakness requiring reconstructive options. 1, 2

Urgent Reassessment Triggers (At Any Time)

Refer immediately for:

• New or worsening neurologic findings 1, 2, 3
• Development of ocular symptoms 1, 2, 3
• Progressive weakness beyond expected timeline 2

Facial Exercises and Physical Therapy

Do not prescribe physical therapy or facial exercises as primary treatment—there is no evidence they improve outcomes over spontaneous recovery. 2 The AAO-HNS guidelines explicitly state no recommendation can be made due to limited evidence consisting only of case series. 2

Special Populations

Children

Children have better prognosis than adults with higher spontaneous recovery rates (up to 94% for incomplete paralysis). 1, 2 Consider oral corticosteroids for severe or complete paralysis after shared decision-making with caregivers, but acknowledge that pediatric-specific evidence is limited. 2 Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper if treating. 2

Pregnant Women

Treat pregnant women with oral corticosteroids within 72 hours using individualized risk-benefit assessment—pregnancy is not a contraindication. 1, 2 Eye protection measures are essential and safe in pregnancy. 2

Prognosis

Set realistic expectations:

• Incomplete paralysis: 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, 2
• Complete recovery typically occurs within 3-4 months 2

Surgical Decompression

Do not perform surgical decompression except in rare cases at specialized centers—it is not recommended as routine treatment. 2 The only potential indication is traumatic facial nerve palsy with >90% amplitude reduction on electrodiagnostic testing, performed within 3-14 days of injury. 2

Common Pitfalls to Avoid

• Starting steroids after 72 hours provides no benefit and exposes patients to unnecessary risks 1, 2
• Prescribing antiviral monotherapy is ineffective and delays appropriate corticosteroid treatment 1, 2, 3
• Inadequate eye protection leads to preventable corneal damage 1, 2
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1, 2
• Ordering routine labs or imaging for typical presentations increases costs without benefit 2, 3
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) delays diagnosis of alternative conditions 2, 3