What is the recommended management for acute Bell's palsy?

Treatment of Bell's Palsy

Immediate First-Line Treatment

All patients 16 years and older with Bell's palsy must receive oral corticosteroids within 72 hours of symptom onset—this is the only proven effective treatment and significantly improves complete recovery rates from 63.6% to 83.0% at 3 months and from 81.6% to 94.4% at 9 months. 1, 2, 3

Corticosteroid Regimen Options

Choose one of these evidence-based regimens:

• Prednisolone 50 mg orally once daily for 10 days 1, 2, 4
• Prednisone 60 mg orally once daily for 5 days, followed by a 5-day taper 1, 2, 4

Critical timing: Treatment initiated beyond 72 hours provides no benefit—this is an absolute deadline. 1, 2, 4

Antiviral Therapy: Minimal Role

Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 4, 3

• Antivirals (valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days) may be added to corticosteroids within 72 hours, but the added benefit is minimal 1, 5, 6
• The landmark 2007 trial showed no benefit of acyclovir alone (71.2% recovery) versus no acyclovir (75.7% recovery) at 3 months 3
• Combination therapy may reduce synkinesis rates, but corticosteroids remain the cornerstone 5

Mandatory Eye Protection

All patients with impaired eye closure require aggressive eye protection immediately to prevent permanent corneal damage. 1, 2, 4

Daytime Protection

• Lubricating eye drops every 1-2 hours while awake 1, 4
• Sunglasses outdoors to protect against wind and particles 1, 4

Nighttime Protection

• Ophthalmic ointment at bedtime for sustained moisture 1, 4
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 4

Urgent Ophthalmology Referral Needed For:

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

Initial Diagnostic Assessment

Bell's palsy is a diagnosis of exclusion—perform a focused history and physical examination to rule out alternative causes before initiating treatment. 1, 2, 4

Key Examination Features

• Forehead involvement: Bell's palsy affects the forehead; stroke spares it 2, 7
• Acute onset: Symptoms develop over 24-72 hours 1, 2
• Unilateral weakness: Bilateral weakness suggests alternative diagnosis 1, 4
• Document severity using House-Brackmann grading scale 1, 4

Red Flags Requiring Imaging (MRI with and without contrast)

• Bilateral facial weakness 1, 4
• Isolated branch paralysis 1, 4
• Other cranial nerve involvement 1, 4
• Recurrent paralysis on same side 1
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1, 4

Do NOT order routine laboratory tests or imaging for typical presentations—this increases costs without benefit and delays treatment. 1, 2, 4

Follow-Up Schedule

Early Reassessment (1-2 weeks)

• Monitor recovery progress 4
• Reinforce eye protection 4
• Identify complications 4

Mandatory 3-Month Reassessment

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months—approximately 30% of patients may have permanent facial weakness requiring reconstructive options. 1, 2, 4

Urgent Reassessment Triggers (at any time)

• New or worsening neurologic findings 1, 2, 4
• Development of ocular symptoms 1, 2, 4
• Progressive weakness beyond expected timeline 1

Special Populations

Children

• Better prognosis with up to 90% spontaneous recovery 4, 5
• Evidence for corticosteroid benefit is less conclusive than in adults 1, 4
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 2, 4

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 4
• Eye protection measures are essential and safe in pregnancy 4

Diabetic Patients

• Diabetes is NOT a contraindication to corticosteroids 1
• Monitor blood glucose every 2-4 hours during first few days 1
• Proactively adjust diabetes medications to counter steroid-induced hyperglycemia 1
• The therapeutic benefit outweighs the risk of temporary hyperglycemia 1

Prognosis

Expected Recovery Rates

• 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 1

Therapies NOT Recommended

Do NOT offer the following—they lack proven benefit or have insufficient evidence: 1, 2, 4

• Physical therapy (no proven benefit over spontaneous recovery) 1, 6
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 6
• Surgical decompression (rarely indicated except in specialized cases) 1, 4
• Electrodiagnostic testing for incomplete paralysis 1, 4

Critical Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 2, 4
• Prescribing antiviral monotherapy is completely ineffective 1, 2, 4, 3
• Inadequate eye protection monitoring can cause permanent corneal damage 1, 4
• Failing to refer at 3 months delays reconstructive options 1, 2, 4
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses 1, 4, 7
• Ordering routine labs or imaging for typical presentations wastes resources 1, 2, 4