What is the recommended first‑line management for acute Bell’s palsy, including steroid regimen, timing of initiation, antiviral use, eye protection, and follow‑up?

Bell's Palsy: First-Line Management

Immediate Treatment (Within 72 Hours)

Prescribe oral corticosteroids immediately for all patients ≥16 years presenting within 72 hours of symptom onset—this is the only proven effective treatment and significantly improves complete recovery rates. 1, 2

Steroid Regimen Options

• Prednisolone 50 mg once daily for 10 days (no taper required) 1, 2
• OR prednisone 60 mg once daily for 5 days, followed by a 5-day taper 1, 2
• Treatment beyond 72 hours provides no benefit—the therapeutic window is absolute 1, 2, 3

Evidence for Steroids

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo (absolute benefit 19.4%; NNT = 6) 1, 2
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo (absolute benefit 12.8%; NNT = 8) 1, 2

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Antiviral Therapy

Do not prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 4

Optional Combination Therapy

• May add valacyclovir 1000 mg three times daily for 7 days or acyclovir 400 mg five times daily for 10 days to steroids within 72 hours 1, 2
• The added benefit is minimal: 96.5% complete recovery with combination versus 89.7% with steroids alone (absolute benefit 6.8%) 1, 5
• The American Academy of Neurology classifies this as an "option" rather than a recommendation, acknowledging the benefit is modest at best 4
• Counsel patients that antiviral benefit has not been established and, if present, is likely very small 4

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Mandatory Eye Protection (All Patients with Incomplete Eye Closure)

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

Daytime Measures

• Lubricating ophthalmic drops every 1–2 hours while awake 1, 2
• Sunglasses outdoors to protect against wind, particles, and foreign bodies 1, 2

Nighttime Measures

• 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
• Consider moisture chambers using polyethylene covers for severe cases 1

Urgent Ophthalmology Referral

• Immediate referral for severe impairment with complete inability to close the eye 1
• Immediate referral for any signs of corneal exposure, damage, eye pain, vision changes, redness, discharge, or foreign body sensation 1

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Initial Diagnostic Assessment

Perform a focused history and physical examination to exclude identifiable causes—Bell's palsy is a diagnosis of exclusion. 1, 2, 6

Key History Elements

• Onset within 72 hours is characteristic; gradual progression beyond 3 weeks suggests tumor or infection 7, 6
• Unilateral facial weakness involving the forehead 1, 6
• Associated symptoms: ipsilateral ear/facial pain, taste disturbance, hyperacusis, dry eye 1, 6
• Exclude trauma, infection (Lyme disease, herpes zoster), tumor, stroke, sarcoidosis 6

Critical Physical Examination

• Test forehead function—inability to wrinkle forehead or raise eyebrow confirms peripheral (not central) lesion 1, 6
• Complete cranial nerve examination—involvement of any other cranial nerve excludes Bell's palsy and mandates imaging 1, 6
• Document severity using House-Brackmann grading scale (Grade 1 = normal; Grade 6 = total paralysis) 1, 2

What NOT to Order

• Do not obtain routine laboratory tests—they delay treatment beyond the 72-hour window without improving outcomes 1, 2
• Do not perform routine imaging—reserve MRI with and without contrast for atypical presentations only 1, 2

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Red Flags Requiring Imaging or Specialist Referral

Order MRI with and without contrast immediately if any of the following are present: 1, 2

• Bilateral facial weakness (rare in Bell's palsy; suggests Lyme disease, sarcoidosis, Guillain-Barré) 6
• Forehead sparing (indicates central stroke, not peripheral palsy) 6
• Isolated branch paralysis (suggests selective nerve pathology) 1
• Other cranial nerve involvement (indicates skull base or brainstem disease) 1, 6
• Recurrent paralysis on the same side (suggests tumor) 1
• Progressive weakness beyond 3 weeks (raises concern for neoplasm or infection) 1
• No recovery after 3 months (indicates possible non-idiopathic cause) 1

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Follow-Up Schedule

Early Reassessment (1–2 Weeks)

• Monitor recovery progress, reinforce eye protection, identify complications 1, 2

Mandatory Reassessment at 3 Months

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months—approximately 30% of patients experience permanent facial weakness requiring long-term management. 1, 2

Urgent Reassessment Triggers (At Any Time)

• New or worsening neurologic findings at any point 1, 2
• Development of ocular symptoms at any point 1, 2

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Special Populations

Children

• Better prognosis than adults with higher spontaneous recovery rates (up to 90%) 1, 2
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 1, 2
• Evidence for steroid benefit in children is inconclusive 1

Pregnancy

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2
• Eye protection measures are essential and safe in pregnancy 1

Diabetes

• Diabetes is not a contraindication to corticosteroid therapy 1
• The therapeutic benefit outweighs the risk of temporary hyperglycemia 1
• Monitor capillary blood glucose every 2–4 hours during the first few days of steroid therapy 1
• Proactively adjust diabetes medications: increase basal insulin and add or increase prandial insulin as needed 1

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Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates the effectiveness of corticosteroid therapy 1, 2
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 4
• Inadequate eye protection monitoring can lead to permanent corneal damage 1, 2
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1, 2
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 6
• Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2

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Therapies NOT Recommended

Do not offer the following interventions—they have no proven benefit: 1, 2

• Physical therapy (no proven benefit over spontaneous recovery) 1, 2
• Acupuncture (poor-quality trials; indeterminate benefit-harm ratio) 1, 2
• Surgical decompression (rarely indicated except in highly selected cases at specialized centers) 1, 2
• Electrodiagnostic testing for incomplete paralysis (provides no actionable information) 1, 2