What is the recommended acute management for Bell's palsy in an otherwise healthy adult?

Acute Management of Bell's Palsy

Start oral corticosteroids immediately—within 72 hours of symptom onset—for all otherwise healthy adults aged 16 and older, using either prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper. 1, 2, 3

Immediate Treatment Protocol (Within 72 Hours)

Corticosteroid Therapy (Mandatory)

• Initiate treatment within 72 hours of symptom onset—this is the critical therapeutic window; no benefit exists beyond this timeframe 1, 2, 3
• Choose one evidence-based regimen:
  • 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 (50→40→30→20→10 mg) over the next 5 days 1, 2
• Evidence of benefit: 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo (absolute benefit 19.4%, NNT=6), and 94.4% recovery at 9 months versus 81.6% with placebo 1, 4

Antiviral Therapy (Optional, Minimal Benefit)

• Never prescribe antivirals alone—they are completely ineffective as monotherapy and delay appropriate corticosteroid treatment 1, 2, 3, 4
• May add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours 1, 5
• The added benefit is minimal: one small trial showed 96.5% recovery with combination therapy versus 89.7% with steroids alone (absolute benefit 6.8%), but the large BELLS trial found no statistically significant advantage (71.2% with acyclovir vs 75.7% without, P=0.50) 1, 4

Mandatory Eye Protection (All Patients with Incomplete Eye Closure)

Daytime Measures

• Lubricating eye drops every 1–2 hours while awake to prevent corneal drying 1, 2, 3
• Sunglasses outdoors to protect against wind, debris, and foreign particles 1, 2

Nighttime Measures

• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2, 3
• 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 If:

• Severe impairment with complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation despite protection measures 1
• Signs of corneal exposure or damage 1

Initial Diagnostic Assessment

History Red Flags (Exclude Alternative Diagnoses)

• Gradual progression beyond 3 weeks suggests tumor or infection rather than Bell's palsy 1
• Associated neurologic symptoms (dizziness, dysphagia, diplopia, limb weakness, sensory changes) exclude Bell's palsy and indicate central or brainstem pathology 1
• Bilateral facial weakness is rare in Bell's palsy and suggests alternative diagnosis 1, 2
• Forehead sparing indicates central stroke rather than peripheral Bell's palsy 1, 3

Physical Examination Essentials

• Test forehead function—inability to wrinkle forehead or raise eyebrow confirms peripheral (not central) facial palsy 1, 3
• Complete cranial nerve examination—involvement of any cranial nerve other than CN VII excludes Bell's palsy 1, 2
• Grade severity using House-Brackmann scale (1=normal to 6=complete paralysis) 1, 2

What NOT to Order

• No routine laboratory tests—they delay treatment beyond the 72-hour window without improving outcomes 1, 2, 3
• No routine imaging—reserve MRI with and without contrast only for atypical presentations 1, 2, 3
• No electrodiagnostic testing for incomplete facial paralysis—it provides no actionable information 1, 2

Follow-Up Schedule

Early Reassessment (1–2 Weeks)

• Monitor recovery progress and reinforce eye protection 2
• Identify early complications or new neurologic findings 2

Mandatory 3-Month Reassessment

• Refer to facial nerve specialist if recovery is incomplete at 3 months after symptom onset 1, 2, 3
• Approximately 30% of patients may have permanent facial weakness requiring long-term management 1, 2

Urgent Referral Triggers (At Any Time)

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

MRI Indications (Red Flags Only)

Order MRI with and without contrast if any of the following are present:

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

Prognosis

• Incomplete paralysis: up to 94% complete recovery 1, 3
• Complete paralysis: approximately 70% complete recovery within 6 months 1, 3
• Most patients begin showing recovery within 2–3 weeks 1, 3
• Complete recovery typically occurs within 3–4 months for most patients 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 2, 3
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 3, 4
• Inadequate eye protection can lead to permanent corneal damage 1, 2, 3
• Using standard methylprednisolone dose pack provides only 105 mg prednisone-equivalent versus the required 540 mg total—this is significant underdosing 1
• Ordering routine labs or imaging for typical presentations increases costs and delays treatment without benefit 1, 2, 3
• Missing forehead involvement can lead to misdiagnosis of stroke as Bell's palsy 1, 3
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1, 2

Therapies NOT Recommended

• Physical therapy—no proven benefit over spontaneous recovery 1, 2
• Acupuncture—poor-quality trials with indeterminate benefit-harm ratio 1, 2
• Surgical decompression—rarely indicated except in specialized centers for select cases 1, 2