What is the recommended management for acute idiopathic facial palsy (Bell's palsy) presenting within 72 hours?

Management of Bell's Palsy

Start oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—this is the only proven treatment that improves recovery. 1, 2

Immediate Treatment (Within 72 Hours)

Corticosteroid Therapy – The Cornerstone

• Prescribe prednisolone 50 mg once daily for 10 days (no taper needed) OR prednisone 60 mg once daily for 5 days followed by a 5-day taper (reducing by 10 mg each day: 50→40→30→20→10 mg, stopping on day 11). 1, 2

• This regimen increases complete recovery at 3 months from 64% (placebo) to 83%—an absolute benefit of 19%, meaning you need to treat only 6 patients to achieve one additional complete recovery. 1, 2

• At 9 months, recovery improves from 82% to 94% with steroids. 1, 2

• Do not delay treatment to obtain labs or imaging—every hour counts within the 72-hour window, and routine testing provides no benefit while risking treatment delay. 1, 2

Antiviral Therapy – Optional, Minimal Benefit

• Never prescribe antivirals alone—they are completely ineffective as monotherapy and delay appropriate steroid treatment. 1, 2

• You may add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to steroids within 72 hours, but the added benefit is small (recovery increases from ~90% to ~96%). 1, 2, 3

• The American Academy of Otolaryngology classifies combination therapy as an "option" rather than a recommendation—reserve it for severe cases with complete paralysis or intense pain. 1, 2

Special Populations

• Diabetes is NOT a contraindication to steroids—the therapeutic benefit outweighs temporary hyperglycemia. Monitor blood glucose every 2–4 hours during the first few days and proactively increase insulin doses. 1

• Pregnant women should receive steroids within 72 hours after individualized risk-benefit discussion; pregnancy increases Bell's palsy risk and recovery rates remain excellent (up to 90%). 1, 2, 3

• Children have better spontaneous recovery (up to 90%) than adults, and steroid benefit is less clear in pediatrics—involve caregivers in shared decision-making. 1, 2

Mandatory Eye Protection (All Patients)

Implement aggressive corneal protection immediately for any patient with incomplete eye closure—this prevents permanent corneal damage and is as important as steroid therapy. 1, 2

Daytime Protection

• Apply lubricating ophthalmic drops (e.g., hydroxypropyl methylcellulose) every 1–2 hours while awake—these hydrate without blurring vision. 1, 2

• Prescribe sunglasses for outdoor use to shield against wind, debris, and UV exposure. 1, 2

Nighttime Protection

• Apply ophthalmic ointment (e.g., dexpanthenol) at bedtime for sustained moisture retention through the night. 1, 2, 4

• Use eye taping or patching at night—instruct patients carefully on proper technique (tape horizontally across the closed lid, avoiding pressure on the globe) to prevent corneal abrasion. 1, 2

• Consider moisture chambers (polyethylene covers) for severe lagophthalmos. 1, 2

Urgent Ophthalmology Referral

• Refer immediately if the patient has complete inability to close the eye, eye pain, vision changes, redness, discharge, or foreign body sensation despite protection measures. 1

Diagnostic Approach – What NOT to Do

• Do not order routine laboratory tests—they delay treatment beyond the critical 72-hour window and provide no diagnostic value for typical Bell's palsy. 1, 2

• Do not obtain routine imaging (CT or MRI)—reserve MRI with and without contrast only for atypical features. 1, 2

• Do not perform electrodiagnostic testing in patients with incomplete paralysis—it provides no actionable information. 1, 2

Red Flags Requiring MRI and Specialist Referral

Order imaging and refer urgently if any of these features are present:

• Forehead sparing (suggests central stroke, not Bell's palsy) 1
• Bilateral facial weakness (extremely rare in Bell's palsy) 1
• Other cranial nerve involvement (indicates brainstem or skull base pathology) 1
• Recurrent paralysis on the same side (suggests tumor) 1
• Isolated branch paralysis (e.g., only lower face affected) 1
• Progressive weakness beyond 3 weeks (raises concern for neoplasm) 1
• Gradual onset over weeks (not consistent with Bell's palsy) 4, 5

Follow-Up and Reassessment

Expected Recovery Timeline

• Most patients begin showing recovery within 2–3 weeks of symptom onset. 1

• Complete recovery typically occurs within 3–4 months. 1

• Approximately 70% of patients with complete paralysis recover fully within 6 months even without treatment; those with incomplete paralysis have recovery rates up to 94%. 1, 2

Mandatory Referral Triggers

• Incomplete facial recovery at 3 months—refer to a facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options (eyelid weights, nerve transfers, static slings). 1, 2

• New or worsening neurologic findings at any point—refer immediately to exclude stroke, tumor, or CNS pathology. 1, 2

• Development of ocular symptoms at any point—refer to ophthalmology to prevent permanent corneal damage. 1, 2

Therapies NOT Recommended

• Physical therapy and acupuncture have no proven benefit over spontaneous recovery—do not delay steroid treatment to pursue these modalities. 1, 2

• Surgical decompression is rarely indicated and should only be considered in highly specialized centers for select cases. 1, 2

Common Pitfalls to Avoid

• Starting steroids after 72 hours provides no benefit and exposes patients to medication risks without improving outcomes. 6, 1

• Using a standard methylprednisolone dose pack delivers only ~105 mg prednisone-equivalent over 6 days, far below the required ~540 mg total exposure—this represents significant underdosing. 1

• Improper eye taping technique (taping vertically or applying pressure to the globe) can cause corneal abrasion—demonstrate proper horizontal taping across the closed lid. 1, 2

• Failing to refer at 3 months delays access to reconstructive surgery and psychological support for patients with permanent facial asymmetry, depression, and social isolation. 1

• Missing forehead involvement on exam leads to misdiagnosis—always test the patient's ability to wrinkle the forehead and raise the eyebrows to distinguish peripheral (Bell's palsy) from central (stroke) facial weakness. 1, 3