Initial management of Bell’s palsy

Diagnosis: A Clinical Diagnosis of Exclusion

Onset: Fast (usually over hours to 72 hours). If onset over minutes to hours, consider alternative diagnosis.
Distribution: Involves both upper and lower face (e.g., inability to close eye and drooping of mouth).
Key differentiator: Forehead involvement helps distinguish Bell’s palsy from a central cause like stroke, where forehead sparing is typical due to bilateral cortical innervation.
Red flags: Gradual or very rapid onset, bilateral symptoms, recurrent episodes, associated systemic symptoms (fever, vesicular rash, hearing loss) may suggest alternative diagnoses (e.g., Lyme disease, Ramsay Hunt syndrome, neoplasm, stroke).

Indication: All patients with new-onset Bell’s palsy within 72 hours of symptom onset. Evidence for benefit if given after 72 hours not currently available.
Regimen: Prednisone 70 mg/day for 3 days, followed by a taper over the next 7 days.
Efficacy: Significantly improves likelihood of full recovery (Number Needed to Treat ≈ 10 patients). See Cochrane review for details (https://www.cochrane.org/CD001942/NEUROMUSC_corticosteroids-bells-palsy)

When to consider: Moderate to severe cases (House-Brackmann Grade IV or higher), or if vesicular lesions suggest herpes zoster (Ramsay Hunt syndrome).
Agents: Acyclovir 800 mg 5x/day or Valacyclovir 1000 mg 3x/day for 7 days.
Evidence: Antivirals alone have not shown a significant improvement in patient outcome. There was a slight reduction in rate of synkinesis (facial tightness) in the long-term if given in combination with steroids. See Cochrane review for details (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.cd001869.pub9/full)

Rationale: The facial weakness leads to an inability to close the eye. This results in drying of the cornea and the risk of developing exposure keratopathy and corneal ulceration. The resulting scarring then leads to long-term visual loss. Those with an absent Bell’s reflex (10% of population) are at a particularly high risk.
Management
- Artificial tears during the day
- Ointment and eye taping at night. Insert link to Facial Palsy DVD 1 - Management of Flaccid Paralysis - Eye care
- Referral to ophthalmology for significant exposure keratopathy

Reassure patients: Approximately 75% fully recover completely within 3–6 months.
Recovery should begin within the first 3 weeks. If no recovery in the first 3 weeks, referral for further investigations is necessary.
Educate about expected time course and the importance of adherence to therapy.
Discuss signs that should prompt re-evaluation (worsening weakness, pain, systemic symptoms).

Early corticosteroid therapy (within 72 hours) remains the cornerstone of Bell’s palsy management.
Low threshold for also given anti-viral treatment.
Don’t underestimate the importance of eye protection and patient education.
Maintain a high index of suspicion for alternate diagnoses when presentation deviates from typical patterns.