What are the next steps in the management of acute Bell's palsy?

Management of Bell's Palsy

Start oral corticosteroids immediately—prednisolone 50 mg once daily for 10 days OR prednisone 60 mg once daily for 5 days followed by a 5-day taper—within 72 hours of symptom onset for all patients ≥16 years old, as this significantly improves complete recovery rates from 64% to 83% at 3 months. 1, 2

Immediate Actions (Within 72 Hours)

Corticosteroid Therapy

• Initiate treatment within 72 hours of symptom onset; there is no benefit beyond this window 1, 2
• Choose one of two evidence-based regimens:
  • Prednisolone 50 mg once daily for 10 days (no taper required) 1, 2
  • 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
• Evidence shows 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1
• Do NOT delay treatment to await laboratory or imaging results, as this compromises the critical 72-hour window 1, 2

Antiviral Therapy Decision

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 2, 3
• 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, 4
• The added benefit is minimal (96.5% vs 89.7% recovery with steroids alone), so this is optional rather than mandatory 1

Mandatory Eye Protection

Implement aggressive eye protection immediately for all patients with incomplete eye closure to prevent permanent corneal damage: 1, 2

Daytime measures:

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

Nighttime measures:

• Ophthalmic ointment at bedtime for sustained moisture 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 if:

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1

Diagnostic Assessment

What NOT to Order

• Do NOT obtain routine laboratory tests—they delay treatment without improving outcomes 1, 2, 5
• Do NOT perform routine imaging (CT or MRI) for typical presentations 1, 2, 5
• Do NOT order electrodiagnostic testing for patients with incomplete facial paralysis 1, 2

Physical Examination Essentials

• Test forehead function (ability to wrinkle brow)—forehead involvement confirms peripheral lesion; forehead sparing suggests central stroke 1, 5, 3
• Perform complete cranial nerve examination—any additional cranial nerve deficit excludes Bell's palsy 1, 5
• Document severity using House-Brackmann grading scale (1 = normal to 6 = complete paralysis) 1, 2
• Assess eye closure carefully to determine risk of corneal exposure 1, 5

Red Flags Requiring MRI with Contrast

Order MRI (with and without contrast) if any of the following are present: 1, 2, 5

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

Follow-Up Schedule

Early Reassessment (1–2 Weeks)

• Monitor recovery progress and trajectory 2
• Reinforce eye protection techniques 2
• Identify early complications or new neurologic findings 2

Mandatory 3-Month Reassessment

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months, as approximately 30% of patients may have permanent facial weakness requiring: 1, 2

• Evaluation for reconstructive procedures (eyelid weights, brow lifts, facial slings, nerve transfers) 1
• Ophthalmology referral for persistent eye closure problems 1
• Psychological support for depression and quality-of-life issues 1

Also refer immediately at any time for: 1, 2

• New or worsening neurologic findings
• Development of ocular symptoms

Special Populations

Children

• Children have better prognosis with up to 90% spontaneous recovery 2, 4
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 1, 2
• Evidence for steroid benefit in children is less conclusive than in adults 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2
• Eye protection measures are essential and safe in pregnancy 1, 2
• Pregnant women have up to 90% complete recovery rate 4

Diabetic Patients

• Diabetes is NOT a contraindication to corticosteroids; the therapeutic benefit outweighs temporary hyperglycemia risk 1
• Monitor capillary blood glucose every 2–4 hours during the first few days 1
• Proactively increase basal and prandial insulin doses 1
• Schedule steroids in the morning to align with natural cortisol rhythm 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 2
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 3
• Using standard methylprednisolone dose packs provides only 105 mg prednisone-equivalent versus the required 540 mg, representing significant underdosing 1
• 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, 2, 5
• Ordering unnecessary labs or imaging for typical presentations increases costs and delays treatment without benefit 1, 2, 5

Therapies NOT Recommended

• Physical therapy: No proven benefit over spontaneous recovery 1, 2, 6
• Acupuncture: Poor-quality trials with 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