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Bell Palsy: Treatment & Medication

Author: Bruce Lo, MD, Medical Director, Sentara Norfolk General Hospital; Assistant Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School
Contributor Information and Disclosures

Updated: Oct 27, 2009

Treatment

Emergency Department Care

The primary treatment of patients with Bell's palsy in the ED is pharmacological management. The remainder of care focuses on reassurance, eye care instructions, and appropriate follow-up care.

  • Steroids: Inflammation and edema of the facial nerve is thought to cause the pathogenesis of Bell's palsy.10 Anti-inflammatory medications such as corticosteroids are thoughts to counter these effects.
    • Older studies have shown conflicting results using steroids in treating Bell's palsy.19 These studies have been limited in their size. However, 2 recent randomized controlled trials showed significant improvement in outcomes when prednisolone was started within 72 hours of symptom onset.20,21
    • Based on these 2 studies, steroids should be strongly considered to optimize outcomes. Once the decision to use steroids is made, the consensus is to start immediately.
  • Antiviral agents
    • Evidence evaluating the efficacy of antiviral medicines in Bell's palsy has shown limited benefit,16,22 with 2 recent randomized controlled trials showing no benefit.20,21 However, there is evidence to suggest a large percentage of Bell's palsy cases may result from a viral infection.16,23 Therefore, antiviral agents may be reasonable in certain situations.
    • 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's palsy.30 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's palsy with use of corticosteroids plus antivirals compared with corticosteroids alone (odds ratio 1.50; 95% confidence interval [CI], 0.83-2.69; P=0.18).
    • Contrary to the Quant et al meta-analysis, de Almeida et al found that, when combined with corticosteroids, antiviral agents were associated with greater risk reduction of borderline significance compared with corticosteroids alone (relative risk [RR], 0.75; 95% CI, 0.56-1.00; P =.05).31 Their meta-analysis included 18 trials including 2786 patients. If antivirals are to be initiated, they should be done so in conjunction with corticosteroids. Future studies will be needed to determine which population will most beneift from antiviral therapy.
  • Eye care: Impaired eye closure and abnormal tear flow are common with Bell's palsy. These leave the eyes at risk for corneal drying and foreign body exposure. Manage with tear substitutes, lubricants, and eye protection.
    • Artificial tears: Use these during waking hours to replace diminished or absent lacrimation.
    • Lubricants are used during sleep. They may be used during waking hours if artificial tears cannot provide adequate protection. One disadvantage is blurred vision during waking hours.
    • Eyeglasses or shields protect the eye from injury and reduce drying by decreasing direct contact of air currents with the exposed cornea. Eye patches, however, are ineffective because unopposed third nerve function will result in corneal exposure despite best efforts to approximate eyelid margins.

Consultations

The patient's primary care provider or consultant should provide close follow-up care. Documentation should chart the progress of the patient's recovery.

Opinions widely vary on referral to a specialist. Some specific referral indications are listed below:

  • Neurologist: Consult a neurologist when other neurologic signs are identified on physical examination and for an atypical presentation of Bell's palsy.
  • Ophthalmologist: Consult an ophthalmologist for any unexplained ocular pain or abnormal findings on physical examination of the eyes.
  • Otolaryngologist: Consult an otolaryngologist for patients with persistent paralysis, prolonged weakness of the facial muscles, or recurrent weakness.
  • Surgeon: Surgery to decompress the facial nerve is occasionally recommended for patients with Bell's palsy. Patients with a poor prognosis, identified by facial nerve testing or persistent paralysis, appear to benefit the most from surgical intervention. However, studies have been mixed as far as benefit from surgery.24 It is recommended that if surgery is decided, it should be within 14 days from onset of symptoms.10

Medication

Watchful waiting is an option for management of Bell's palsy, because most cases resolve without medication. However, some individuals with Bell's palsy never fully recover. For both classes of medications listed below, there are clinical trials that support their efficacy and trials that dispute it.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.


Prednisone (Deltasone, Orasone, Sterapred)

Therapeutic success may be the result of anti-inflammatory effect, which presumably decreases compression of the facial nerve in the facial canal.

Adult

1 mg/kg/d PO up to 60 mg/d for 7-10 d

Pediatric

Administer as in adults

Coadministration with estrogens may decrease prednisone 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, fungal, connective tissue, and tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI disease

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; complications of glucocorticoid use include hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections

Antivirals

Herpes simplex infections may be a common cause of Bell's palsy. Acyclovir is the antiviral agent most often used, but others may also be appropriate.

Valacyclovir is a prodrug of acyclovir and produces blood levels of acyclovir that are 3-5 times higher than those produced by oral acyclovir.


Valacyclovir (Valtrex)

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

Adult

1000 mg/24 h PO for 5 d

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


Acyclovir (Zovirax)

Has demonstrated inhibitory activity directed against both HSV-1 and HSV-2, and infected cells selectively take it up.

Adult

4000 mg/24 h PO for 7-10 d

Pediatric

<2 years: Not recommended
>2 years: 1000 mg PO divided qid 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

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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References

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

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  30. [Best Evidence] 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. Sep 7 2009;339:b3354. [Medline].

  31. 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. Sep 2 2009;302(9):985-93. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Bruce Lo, MD, Medical Director, Sentara Norfolk General Hospital; Assistant Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School
Bruce Lo, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Medical Society of Virginia, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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