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

Management of Bell's Palsy

Start oral corticosteroids immediately—within 72 hours of symptom onset—for all patients 16 years 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, and implement aggressive eye protection measures for anyone with incomplete eye closure. 1, 2, 3

Immediate Treatment Window (≤72 Hours)

Corticosteroids are the only proven effective treatment and must be initiated within 72 hours—there is zero benefit beyond this window. 1, 2, 3

Evidence-Based Steroid Regimens

Choose one of these two options:

• Prednisolone 50 mg orally once daily for 10 days (no taper required) 1, 2
• Prednisone 60 mg orally once daily for 5 days, then taper by 10 mg daily (50→40→30→20→10 mg, stopping on day 11) 1, 2

Clinical Efficacy Data

• 83% complete recovery at 3 months with prednisolone versus 64% with placebo (absolute benefit 19%, NNT=6) 1, 2
• 94% complete recovery at 9 months with prednisolone versus 82% with placebo (absolute benefit 12%, NNT=8) 1, 2

Antiviral Therapy: Minimal Role

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

• Antivirals may be added to corticosteroids within 72 hours, but the added benefit is minimal (96.5% recovery with combination versus 89.7% with steroids alone, absolute benefit only 6.8%) 1, 2
• If adding an antiviral, use valacyclovir 1 g three times daily for 7 days or acyclovir 400 mg five times daily for 10 days 1, 2, 5
• This is classified as an "option" rather than a recommendation due to the small incremental gain 1, 2

Mandatory Eye Protection (All Patients with Impaired Eye Closure)

Implement these measures immediately to prevent permanent corneal damage: 1, 2, 3

Daytime Protection

• Lubricating eye drops every 1-2 hours while awake 1, 2, 3
• Sunglasses outdoors to protect against wind and particles 1, 2, 3

Nighttime Protection

• Ophthalmic ointment at bedtime for sustained moisture 1, 2, 3
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2, 3

Severe Cases Requiring Urgent Ophthalmology Referral

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

Initial Diagnostic Assessment

Bell's palsy is a diagnosis of exclusion—perform a focused examination to rule out alternative causes before initiating treatment. 1, 2, 3

Key Physical Examination Findings

• Forehead involvement (inability to wrinkle forehead or raise eyebrow) is mandatory for peripheral facial palsy and distinguishes it from stroke, which spares the forehead 1, 2, 3, 4
• Acute onset over 24-72 hours (gradual progression beyond 3 weeks suggests tumor or infection) 1, 2
• Unilateral facial weakness affecting upper and lower face 1, 2, 6
• Document severity using the House-Brackmann grading scale (Grade 1=normal to Grade 6=total paralysis) 1, 2

Associated Symptoms to Document

• Ipsilateral ear or facial pain 1
• Hyperacusis (increased sound sensitivity) 1, 4
• Taste disturbance on anterior two-thirds of tongue 1
• Dry eye or mouth 1

What NOT to Order (Typical Presentations)

Do not obtain routine laboratory tests or imaging for typical Bell's palsy—this delays treatment beyond the critical 72-hour window without improving outcomes. 1, 2, 3, 4

• No routine labs 1, 2, 3
• No routine CT or MRI 1, 2, 3
• No electrodiagnostic testing for incomplete paralysis (provides no actionable information) 1, 2

Red Flags Requiring MRI with Contrast and Specialist Referral

Order MRI with and without contrast and refer immediately if any of these features are present: 1, 2, 3

• Bilateral facial weakness 1, 2
• Isolated branch paralysis (e.g., only lower face affected) 1, 2
• Other cranial nerve involvement 1, 2
• Forehead sparing (suggests central stroke) 1, 2
• Recurrent paralysis on the same side 1, 2
• Progressive weakness beyond 3 weeks 1, 2
• No recovery after 3 months 1, 2
• New or worsening neurologic findings at any time 1, 2

Follow-Up Schedule

Early Reassessment (1-2 Weeks)

• Monitor recovery progress 1
• Reinforce eye protection measures 1
• Identify early complications 1

Mandatory Reassessment or Referral at 3 Months

Refer to a facial nerve specialist if facial 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
• Reconstructive options include eyelid weights, brow lifts, facial slings, and nerve transfers 1
• Psychological support is essential for quality of life issues 1

Special Populations

Children

• Better prognosis with up to 90% spontaneous recovery 1, 2, 5
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 1, 3
• Evidence for steroid benefit in children is less conclusive than in adults 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2, 3
• Eye protection measures are essential and safe in pregnancy 1
• Recovery rate up to 90% 5

Diabetic Patients

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

Prognosis and Natural History

• Incomplete paralysis: up to 94% complete recovery 1, 2
• Complete paralysis: approximately 70% complete recovery within 6 months 1, 2, 4
• Most patients begin showing recovery within 2-3 weeks 1, 7
• Complete recovery typically occurs within 3-4 months 1

Therapies NOT Recommended

Do not offer these interventions—they have no proven benefit or insufficient evidence: 1, 2, 6

• Physical therapy (no proven benefit over spontaneous recovery) 1, 2, 6
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 2, 6
• Surgical decompression (rarely indicated except in highly selected cases at specialized centers) 1, 2
• Electrodiagnostic testing for incomplete paralysis 1, 2

Critical Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 3
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 3
• Inadequate eye protection monitoring can lead to permanent corneal damage, particularly with severe lagophthalmos 1, 3
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1, 3
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 2, 3
• Ordering routine labs or imaging for typical presentations increases costs without benefit and delays treatment 1, 2, 3
• Using a standard methylprednisolone dose pack provides only 105 mg prednisone-equivalent versus the required 540 mg total exposure, representing significant underdosing 2