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Bell Palsy Empiric Therapy 

  • Author: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Thomas E Herchline, MD  more...
 
Updated: Aug 12, 2015
 
 

Empiric Therapy Regimens

Empiric therapeutic regimens for Bell palsy are outlined below, including those for corticosteroid treatment and eye care.

The most widely accepted treatment for Bell palsy is corticosteroids. Multiple randomized controlled trials show benefit with the use of corticosteroids.[1, 2, 3, 4, 5] The revised 2012 guidelines for Bell palsy issued by the American Academy of Neurology support the use of corticosteroids and rate them as “highly effective.”[6]

Antiviral agents have also been studied in this setting and may be used in conjunction with corticosteroids. Evidence suggests antivirals have no benefit by themselves.[1, 7, 8, 2, 3, 4] Two meta-analyses showed conflicting conclusions for the value of combining antiviral agents and corticosteroids.[9, 10] However, more recent evidence suggests that a combination of antivirals and corticosteroids is more effective than corticosteroids alone.[11, 12, 13] If antivirals are used, they should be used in combination with corticosteroids.

The following guidelines from the American Academy of Otolaryngology–Head and Neck Surgery Foundation were issued in November 2013 and support the use of corticosteroids and the optional use of antiviral agents[14] :

  • Assess patients presenting with acute-onset unilateral facial paralysis to exclude other identifiable causes (eg, herpes zoster, Lyme disease, sarcoidosis)
  • Routine laboratory testing and diagnostic imaging are not recommended for patients with new-onset palsy
  • Oral corticosteroids should be given within 72 hours of symptom onset in patients aged 16 years or older
  • Antiviral monotherapy should not be given in new-onset disease; antiviral agents may be offered in combination with corticosteroids

Corticosteroid regimens should be initiated within 72 hours of symptoms. Examples include the following:

  • Prednisone 1 mg/kg PO or 60 mg/day for 5d, then tapered over 5d, for a total of 10d or
  • Prednisolone 25 mg PO BID for 5 d, then tapered over 5 d, for a total of 10d

If herpes simplex virus (HSV-1 or HSV-2) or varicella zoster virus (VZV) is suspected as the etiology, an antiviral agent may be added to the oral corticosteroid, as follows:

Caution should be taken when using high-dose valacyclovir in VZV owing to possible adverse effects. Caution should be taken with corticosteroid usage in patients who are pregnant, have an active infection (eg, tuberculosis, sepsis), or are immunocompromised.[15]

Eye care

Impaired eye closure and abnormal tear flow are common with Bell palsy; these leave the eyes at risk for corneal drying and foreign-body exposure.

  • Manage with tear substitutes, lubricants, and eye protection.
  • Use artificial tears during waking hours to replace diminished or absent lacrimation.
  • Lubricants are used during sleep, and they may be used during waking hours if artificial tears cannot provide adequate protection.
  • Eyeglasses or shields protect the eye from injury and reduce drying by decreasing direct contact of air currents with the exposed cornea.
  • Eye patches are ineffective, because unopposed third nerve function will result in corneal exposure despite best efforts to approximate eyelid margins.

Special considerations

The majority of cases will resolve without treatment; patients with severe symptoms are more likely to have residual symptoms.

The potential for benefit is greater if treatment is started within 72h of symptom onset.

Corticosteroids are rated as "highly effective".

Antivirals are rated as “possibly effective” only when combined with corticosteroids.

Herpes simplex virus (HSV) infection is more common than VZV as a cause for Bell palsy.

There is no evidence that surgery is beneficial.

 
Contributor Information and Disclosures
Author

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Associate Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of Ohio, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References
  1. Engstrom M, Berg T, Stjernquist-Desatnik A, Axelsson S, Pitkaranta A, Hultcrantz M, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. 2008 Nov. 7(11):993-1000. [Medline].

  2. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, et al. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med. 2007 Oct 18. 357(16):1598-607. [Medline].

  3. Axelsson S, Berg T, Jonsson L, Engström M, Kanerva M, Stjernquist-Desatnik A. Bell's palsy - the effect of prednisolone and/or valaciclovir versus placebo in relation to baseline severity in a randomised controlled trial. Clin Otolaryngol. 2012 Aug. 37(4):283-90. [Medline].

  4. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, et al. A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell's palsy: the BELLS study. Health Technol Assess. 2009 Oct. 13(47):iii-iv, ix-xi 1-130. [Medline].

  5. Berg T, Bylund N, Marsk E, Jonsson L, Kanerva M, Hultcrantz M, et al. The effect of prednisolone on sequelae in Bell's palsy. Arch Otolaryngol Head Neck Surg. 2012 May. 138(5):445-9. [Medline].

  6. Gronseth GS, Paduga R,. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012 Nov 27. 79(22):2209-13. [Medline].

  7. Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001 Apr 10. 56(7):830-6. [Medline].

  8. Lockhart P, Daly F, Pitkethly M, Comerford N, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7. CD001869. [Medline].

  9. Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis. BMJ. 2009 Sep 7. 339:b3354. [Medline]. [Full Text].

  10. de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009 Sep 2. 302(9):985-93. [Medline].

  11. Hato N, Yamada H, Kohno H, Matsumoto S, Honda N, Gyo K, et al. Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol. 2007 Apr. 28(3):408-13. [Medline].

  12. Lee HY, Byun JY, Park MS, Yeo SG. Steroid-antiviral treatment improves the recovery rate in patients with severe Bell's palsy. Am J Med. 2013 Apr. 126(4):336-41. [Medline].

  13. Shahidullah M, Haque A, Islam MR, Rizvi AN, Sultana N, Mia BA. Comparative study between combination of famciclovir and prednisolone with prednisolone alone in acute Bell's palsy. Mymensingh Med J. 2011 Oct. 20(4):605-13. [Medline].

  14. Baugh R, Basura G, Ishii L, Schwartz S, Drumheller C, Burkholder R, et al. Clinical Practice Guideline: Bell’s Palsy. Otolaryngol Head Neck Surg November 2013 vol. 149 no. 3 suppl S1-S27. [Full Text].

  15. Taylor DC, Khoromi S, Zachariah SB. Bell Palsy. Medscape Reference. Available at http://emedicine.medscape.com/article/1146903-overview.. Accessed: May 12, 2013.

 
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