What is the recommended treatment for Bell's palsy in an adolescent (12‑18 years old)?

Treatment of Bell's Palsy in Adolescents

Adolescents (12-18 years) with Bell's palsy should receive oral corticosteroids within 72 hours of symptom onset, using the same adult regimen: prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper. 1

Evidence Supporting Treatment in Adolescents

The American Academy of Otolaryngology-Head and Neck Surgery guidelines strongly recommend oral corticosteroids for patients 16 years and older, which includes most adolescents in the 12-18 age range. 1 The evidence is compelling:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo (NNT = 6) 1
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo (NNT = 8) 1

For adolescents under 16 years, the evidence is less robust. A 2022 randomized controlled trial in children showed no significant benefit at 1 month (49% recovery with prednisolone vs 57% with placebo), though the study was underpowered. 2 However, children generally have excellent prognosis with 80-90% spontaneous recovery rates. 3

Treatment Algorithm by Age

Ages 16-18 years:

• Prescribe oral corticosteroids within 72 hours using adult dosing 1
• Prednisolone 50 mg once daily for 10 days (no taper needed) OR 1
• Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily over 5 days 1

Ages 12-15 years:

• Consider weight-based dosing: prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5-10 days followed by 5-day taper 3
• Engage the adolescent and caregivers in shared decision-making, explaining that pediatric evidence is less conclusive but treatment is generally safe 3
• For severe or complete paralysis, treatment is more strongly justified 3
• For incomplete paralysis, observation with aggressive eye protection is reasonable given excellent prognosis (up to 94% recovery) 3

Critical Timing Window

Treatment must begin within 72 hours of symptom onset. 1 Studies demonstrating benefit specifically enrolled patients within this window. 4 Treatment started after 72 hours provides no proven benefit and unnecessarily exposes patients to medication risks. 4, 3

Treatment within 24-48 hours yields the highest recovery rates (66-76% complete recovery) compared to 49-72 hours. 5

Mandatory Eye Protection Protocol

All adolescents with impaired eye closure require immediate aggressive eye protection to prevent corneal damage, regardless of whether corticosteroids are prescribed: 1, 3

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Ophthalmic ointment at bedtime for sustained moisture 1
• Eye taping or patching at night with proper technique instruction to avoid corneal abrasion 1, 3
• Sunglasses outdoors to protect against wind and debris 1
• Urgent ophthalmology referral if severe impairment with complete inability to close the eye 1

Antiviral Therapy Considerations

Antiviral monotherapy is never appropriate and should never be prescribed. 1, 3 Antivirals alone are completely ineffective. 6, 7

Combination therapy (corticosteroid + antiviral) may be offered within 72 hours for severe cases: 1

• Valacyclovir 1 g three times daily for 7 days OR 1
• Acyclovir 400 mg five times daily for 10 days 1

The added benefit is modest (96.5% vs 89.7% recovery with steroids alone), so this remains an option rather than a strong recommendation. 1

Diagnostic Testing to Avoid

Do NOT routinely order: 1, 3

• Laboratory tests (delay treatment without improving outcomes)
• Imaging studies (reserve MRI for atypical presentations only)
• Electrodiagnostic testing in patients with incomplete paralysis

Follow-Up and Referral Triggers

Mandatory reassessment or specialist referral if: 1, 3

• Incomplete facial recovery at 3 months after symptom onset
• New or worsening neurologic findings at any time
• Development of ocular symptoms at any point

Early follow-up at 1-2 weeks is valuable for monitoring recovery, reinforcing eye protection, and identifying complications. 3

Common Pitfalls to Avoid

• Starting corticosteroids after 72 hours provides no benefit and exposes patients to unnecessary medication risks 4, 3
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 3
• Inadequate eye protection can lead to permanent corneal damage, particularly in severe lagophthalmos 1, 3
• Improper eye taping technique can cause corneal abrasion—provide careful instruction 3
• Failing to refer at 3 months for incomplete recovery delays access to reconstructive options 3
• Overestimating steroid benefit in younger adolescents based on adult data—pediatric evidence is less conclusive 3

Therapies NOT Recommended

The following have no proven benefit and should not be used: 1, 3

• Surgical decompression (except rare, highly selected cases)
• Acupuncture
• Physical therapy as primary treatment