How should I manage an adult who presents within 72 hours of acute Bell's palsy, including corticosteroid regimen, antiviral therapy for diabetic, immunocompromised, or patients over 50, eye protection, facial physiotherapy, and follow‑up schedule?

Management of Bell's Palsy in Adults Presenting Within 72 Hours

Immediate Corticosteroid Therapy

Prescribe oral corticosteroids immediately for all patients ≥16 years presenting within 72 hours of symptom onset—this is the only proven treatment that significantly improves facial nerve recovery. 1

Recommended Steroid Regimens

Choose one of the following evidence-based regimens:

• Prednisolone 50 mg once daily for 10 days (no taper required), OR
• Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily for 5 days (total 10 days) 1

Evidence of benefit: 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo (NNT = 6), and 94.4% recovery at 9 months versus 81.6% with placebo 1, 2

Critical Timing

• Treatment must begin within 72 hours of symptom onset—there is no evidence supporting benefit after this window 1, 3
• Do not delay treatment to obtain laboratory tests or imaging in typical presentations, as this compromises the therapeutic window 1

Special Populations Requiring Corticosteroids

Diabetic patients: Prescribe corticosteroids despite diabetes—the therapeutic benefit outweighs temporary hyperglycemia risk 1

• Monitor capillary blood glucose every 2-4 hours during the first few days 1
• Administer steroids in the morning to align with natural cortisol rhythm 1
• Proactively increase basal and prandial insulin doses 1
• For patients on oral agents, add NPH insulin concurrent with morning steroid dose 1

Immunocompromised patients: Treat identically to immunocompetent patients—corticosteroids remain the standard of care within 72 hours 1

Patients over 50: No special dosing adjustments needed; use standard regimens 1

Pregnant women: Prescribe corticosteroids within 72 hours after individualized risk-benefit discussion—the treatment is appropriate in pregnancy 1

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Antiviral Therapy Decision Algorithm

Antiviral monotherapy should NEVER be prescribed for Bell's palsy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2

Optional Combination Therapy

Adding an antiviral to corticosteroids is optional and provides only minimal incremental benefit (96.5% recovery with combination versus 89.7% with steroids alone—absolute benefit of 6.8%). 1

If you choose to add an antiviral within 72 hours, use:

• Valacyclovir 1000 mg three times daily for 7 days, OR
• Acyclovir 400 mg five times daily for 10 days 1

Key evidence: The large BELLS trial (n=496) found no statistically significant advantage of adding acyclovir: 71.2% recovery with acyclovir versus 75.7% without (P=0.50) at 3 months 1, 2

Special Population Considerations for Antivirals

• Diabetic patients: No specific indication for antivirals; if used, combine with steroids only 1
• Immunocompromised patients: No specific indication for antivirals; if used, combine with steroids only 1
• Patients over 50: No specific indication for antivirals; if used, combine with steroids only 1

Bottom line: The guideline classifies steroid + antiviral as an "option" rather than a recommendation, emphasizing that corticosteroids alone remain the evidence-based standard 1

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Mandatory Eye Protection Protocol

Implement aggressive eye protection immediately for all patients with impaired eye closure—corneal damage is preventable but can be permanent if neglected. 1

Daytime Protection

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

Nighttime Protection

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

Urgent Ophthalmology Referral Triggers

Refer immediately if the patient develops:

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

Common pitfall: Relying solely on drops without nighttime protection can lead to exposure keratitis—always use ointment and/or taping at night 1

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Facial Physiotherapy

Do not prescribe physical therapy or acupuncture as primary treatment for Bell's palsy—there is no proven benefit over spontaneous recovery. 1

The AAO-HNS guideline explicitly states that no recommendation can be made regarding physical therapy due to limited evidence consisting only of case series, and acupuncture trials are of poor quality with indeterminate benefit-harm ratios 1

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Diagnostic Testing: What to Avoid

Do not order routine laboratory tests or imaging for typical Bell's palsy presentations—these delay treatment without improving outcomes. 1

When Imaging IS Required (MRI with and without contrast)

Order MRI only if any of these red flags are present:

• Recurrent paralysis on the same side 1, 4
• Isolated branch paralysis (e.g., only lower face affected) 1
• Other cranial nerve involvement 1
• Bilateral facial weakness 1
• Forehead sparing (suggests central stroke, not Bell's palsy) 1
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1
• New or worsening neurologic findings at any time 1

Electrodiagnostic Testing

• Do NOT perform in patients with incomplete facial paralysis 1
• May offer to patients with complete facial paralysis, ideally 3-14 days after onset 1
• Testing before 7 days or after 14-21 days provides unreliable prognostic information 1

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Follow-Up Schedule

Initial Visit (Within 72 Hours)

• Initiate corticosteroids 1
• Educate on eye protection techniques 1
• Assess severity using House-Brackmann grading system 1

Early Follow-Up (1-2 Weeks)

• Assess recovery trajectory 1
• Reinforce eye protection compliance 1
• Identify early complications 1

Mandatory 3-Month Reassessment

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months after symptom onset. 1

Urgent Referral Triggers (At Any Time)

Refer immediately for:

• New or worsening neurologic findings (suggests alternative diagnosis such as tumor, stroke, or CNS pathology) 1
• Development of ocular symptoms (requires ophthalmology evaluation) 1
• Progressive weakness beyond 3 weeks (raises concern for neoplasm or infection) 1

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Prognosis Counseling

Natural history without treatment:

• 70% of patients with complete paralysis recover fully within 6 months 1
• Up to 94% of patients with incomplete paralysis recover fully 1
• Most patients begin showing recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1

With corticosteroid treatment: Recovery rates improve significantly, with 94.4% complete recovery at 9 months versus 81.6% without treatment 1, 2

Diabetic patients have worse prognosis: Recovery is delayed and facial movement scores remain lower compared to non-diabetic patients (52.6% recovery at 6 months versus 82.5% in non-diabetics) 5

30% may experience permanent facial weakness with muscle contractures requiring long-term reconstructive options 1

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Common Pitfalls to Avoid

• Starting steroids beyond 72 hours provides minimal benefit and exposes patients to medication risks 1, 3
• Using a standard methylprednisolone dose pack delivers only 105 mg prednisone-equivalent versus the required 540 mg total—this is significant underdosing 1
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1
• Failing to provide nighttime eye protection can lead to permanent corneal damage 1
• Ordering unnecessary labs or imaging delays treatment beyond the critical 72-hour window 1
• Missing red-flag features (bilateral weakness, forehead sparing, other cranial nerve involvement) that indicate alternative diagnoses requiring imaging 1
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1