eMedicine Specialties > Neurology > Inflammatory and Demyelinating Diseases

Bell Palsy: Treatment & Medication

Author: Kim Monnell, DO,, Neurology Consulting Staff, Department of Medicine, Bay Pines VA Medical Center
Coauthor(s): Sally B Zachariah, MD, Associate Professor, Department of Neurology, University of South Florida; Director, Department of Neurology, Division of Strokes, Veteran Affairs Medical Center of Bay Pines; Suzan Khoromi, MD, Fellow, Pain and Neurosensory Mechanisms Branch, National Institute of Dental and Cranial Research, National Institutes of Health
Contributor Information and Disclosures

Updated: Oct 26, 2009

Treatment

Medical Care

In general, persons with true Bell palsy have an excellent prognosis. Thus, treatment of Bell palsy is still controversial, because spontaneous recovery is fairly common. The goals of treatment are to improve function of the facial nerve and reduce neuronal damage. Many issues must be addressed in treating patients with Bell palsy. The most important consideration is the onset of symptoms. Treatment may be considered for patients who have the onset of paralysis within 1-4 days of the initial office visit.

The American Academy of Neurology published a practice parameter in 2001 stating that steroids are probably effective and acyclovir (with prednisone) is possibly effective for treatment of Bell palsy. In October 2007, a large double-blinded, placebo-controlled, randomized Scottish study was published.8  The results showed that early treatment with prednisolone alone, and not combined with acyclovir, is effective for Bell palsy. Any recommendation on facial decompression surgery had insufficient evidence.

  • The most widely accepted treatment for Bell palsy is corticosteroids. However, the use of steroids is still controversial because most patients recover without treatment.
    • The recommended dose of prednisone is 1 mg/kg or 60 mg/d for 6 days, followed by a taper, for a total of 10 days.
    • Many trials have been carried out to study the efficacy of prednisone in Bell palsy. Early studies had small numbers of patients and variable outcomes. In 1972, Adour et al conducted a large, controlled clinical trial that found that 89% of patients treated with prednisone had full recovery compared with 64% of patients treated with placebo.9
    • A large Scottish study published in 2007 included 551 patients that were randomized to prednisolone and acyclovir, prednisolone alone, acyclovir alone, and placebo. At 3 months, 83% in the prednisolone group and 63.6% in the placebo group had recovered facial function. At 9 months, 94.4% in the prednisolone group and 81.6% in the placebo group had recovered facial function. The group that was treated with acyclovir did not have a significant improvement in facial function compared with the placebo group. In the double placebo group, 85% had full recovery at 9 months.8
    • When using corticosteroids for the treatment of Bell palsy, caution should be used in patients with tuberculosis, peptic ulcer disease, diabetes mellitus, renal or hepatic dysfunction, or malignant hypertension.
    • Quant et al conducted a meta-analysis of published studies from 1984 to January 2009 to compare use of corticosteroids plus antiviral agents with corticosteroids alone on degree of facial muscle recovery in patients with Bell palsy. Six trials (representing pooled data of 1145 patients) were examined and included 574 patients who received corticosteroids alone and 571 patients who received corticosteroids and antiviral agents. The analysis showed no improved benefit for Bell palsy with use of corticosteroids plus antivirals compared with corticosteroids alone (odds ratio 1.50; 95% confidence interval, 0.83-2.69; P=0.18). The authors suggest the routine use of antivirals is not warranted; however, future studies should improve diagnostic efforts to identify herpes virus as a potential etiology. Additionally, newer antiviral agents may prove more beneficial than older antiviral agents used in the studies analyzed.10
  • Recent guidelines suggest that the use of acyclovir for the treatment of Bell palsy is only possibly effective. They suggest that this agent alone is not effective in facial recovery. The Scottish study suggested that prednisolone, and not acyclovir, is useful for facial recovery in Bell palsy. The dose of acyclovir is 400 mg PO 5 times per day. The dose of valacyclovir, when used with prednisolone, is 1 g/d for 5 days. This combination was recently proven to be effective in a Japanese study.
    • A prospective randomized trial with 101 patients comparing prednisone and acyclovir demonstrated that the prednisone group had a better clinical recovery.11 In another prospective randomized trial with 99 patients, prednisone monotherapy was compared with the combination of prednisone and acyclovir. This study demonstrated that combination therapy was more effective in preventing nerve degeneration as measured by electrodiagnostic tests.12
    • In April 2007, a Japanese randomized prospective study on 221 patients with Bell palsy was published. It showed significant improvement in facial function using both prednisone and valacyclovir therapy as compared with those who used prednisone alone. This improvement was noted in those who had severe to complete facial palsy.13
    • Whether to use prednisone alone or combination therapy is left to the discretion of the treating physician.
  • That eye care is imperative in Bell palsy is accepted universally. The patient's eye is at risk for drying, corneal abrasion, and corneal ulcers. Eye care includes artificial tears for use during the day as well as eyeglasses or shields. At night, eye lubricants may be used. If artificial tears are not effective during the daytime, then lubricants may be used; however, they may cause blurring of vision.

For other views on treatment of Bell palsy, see Medscape's CME activity, Evidence-Based Management of Bell's Palsy: A Best Evidence Review.

Surgical Care

Surgery for Bell palsy is controversial. In the past, surgical decompression of the facial nerve was considered for patients whose facial muscles demonstrated less than 90% of normal activity on electrophysiologic studies. Surgical decompression of the facial nerve involves a middle fossa craniotomy with an extradural approach. However, recent trials suggest this is not beneficial in patients with Bell palsy.

Consultations

If the initial impression based on the history and physical examination is not Bell palsy, then consultation with a neurologist or otolaryngologist is needed. For example, the patient who has facial palsy and pain and in whom the ear, nose, and throat examination does not show auricular vesicles (as in Ramsay Hunt syndrome), then consultation with an otolaryngologist should be made. These patients should be evaluated for malignancy of the seventh nerve.

  • If the paralysis persists for several months, consultation with a neurologist or otolaryngologist should be sought.
  • Patients who report persistent dry eye or painful eye should be referred to an ophthalmologist.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Corticosteroids

Prednisone can be used but has many adverse effects including fluid retention, hypokalemia, myopathy, peptic ulcer, headache (pseudotumor), menstrual irregularities, cataracts, glaucoma, and manifestation of latent diabetes mellitus. Signs of infection may also be masked in patients taking prednisone. Physicians should use caution when using prednisone in patients with the aforementioned conditions.


Prednisone (Deltasone, Orasone, Sterapred)

Glucocorticoid absorbed readily from GI tract. It has anti-inflammatory and immune-modulating effects, and profound and varied metabolic effects.

Adult

1 mg/kg or 60 mg PO qd for 7 d followed by taper for total of 10 d

Pediatric

1 mg/kg PO qd for 6 d followed by taper for total of 10 d

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI bleeding or ulceration

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Antiviral medication

Acyclovir has been used in the treatment of Bell palsy in combination with prednisone or used alone in patients who cannot take prednisone.


Acyclovir (Zovirax)

Prodrug activated by phosphorylation by virus-specific thymidine kinase that inhibits viral replication. Herpes virus thymidine kinase (TK), but not host cells TK, uses acyclovir as a purine nucleoside, converting it into acyclovir monophosphate, a nucleotide analogue. Guanylate kinase converts the monophosphate form into diphosphate and triphosphate analogues that inhibit viral DNA replication.

Has affinity for viral thymidine kinase and once phosphorylated causes DNA chain termination when acted on by DNA polymerase. Inhibits activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative.

Has been used in the treatment of Bell palsy in combination with prednisone or used alone in patients who cannot take prednisone.

Adult

800 mg PO 5 times/d for 10 d

Pediatric

<2 years: Not established
>2 years: 20 mg/kg for 10 d

Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure or when using nephrotoxic drugs


Valacyclovir (Valtrex)

Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.

Adult

2 g PO q12h for 1 day

Pediatric

Not established

Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity of valacyclovir

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure (decrease dose) and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome

More on Bell Palsy

Overview: Bell Palsy
Differential Diagnoses & Workup: Bell Palsy
Treatment & Medication: Bell Palsy
Follow-up: Bell Palsy
Multimedia: Bell Palsy
References
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Further Reading

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Keywords

Bell's palsy, idiopathic facial paralysis, facial nerve compression, acute unilateral facial paralysis, bilateral facial palsy, Guillain-Barré syndrome, GBS, sarcoidosis, Lyme disease, meningitis, neoplastic meningitis, infectious meningitis, bilateral neurofibromas, neurofibromatosis type 2, ipsilateral facial palsy

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Contributor Information and Disclosures

Author

Kim Monnell, DO,, Neurology Consulting Staff, Department of Medicine, Bay Pines VA Medical Center
Kim Monnell, DO, is a member of the following medical societies: American Academy of Neurology and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Sally B Zachariah, MD, Associate Professor, Department of Neurology, University of South Florida; Director, Department of Neurology, Division of Strokes, Veteran Affairs Medical Center of Bay Pines
Sally B Zachariah, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, and American Society of Neuroimaging
Disclosure: none None None

Suzan Khoromi, MD, Fellow, Pain and Neurosensory Mechanisms Branch, National Institute of Dental and Cranial Research, National Institutes of Health
Suzan Khoromi, MD is a member of the following medical societies: American Academy of Neurology, American Pain Society, and International Association for the Study of Pain
Disclosure: Nothing to disclose.

Medical Editor

Milind J Kothari, DO, Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Hershey Medical Center
Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

Chief Editor

B Mark Keegan, MD, FRCPC, Assistant Professor of Neurology, College of Medicine, Mayo Clinic; Master's Faculty, Mayo Graduate School; Consultant, Department of Neurology, Mayo Clinic, Rochester
B Mark Keegan, MD, FRCPC is a member of the following medical societies: American Academy of Neurology, American Medical Association, and Minnesota Medical Association
Disclosure: Nothing to disclose.

 
 
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