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, 6] 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.” [7]
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, 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, 14] 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: [15]
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Assess patients presenting with acute-onset unilateral facial paralysis to exclude other identifiable causes (eg, herpes zoster, Lyme disease, sarcoidosis)
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Routine laboratory testing and diagnostic imaging are not recommended for patients with new-onset palsy
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Oral corticosteroids should be given within 72 hours of symptom onset in patients aged 16 years or older
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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:
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Prednisone 1 mg/kg PO or 60 mg/day for 5d, then tapered over 5d, for a total of 10d or
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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:
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HSV: Acyclovir 400 mg PO 5 times daily for 10d or valacyclovir 500 mg PO BID for 5d
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VZV: Acyclovir 800 mg PO 5 times daily for 10d or valacyclovir 1000 mg PO TID for 5d
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.
July 2020 guidelines from the French Society of ENT (SFORL) also recommend that in cases in which Bell's palsy is confirmed, corticosteroid therapy should be instituted as early as possible, ideally within 72 hours, at a dose of 1mg/kg/day for 7–10 days. They also recommend antiviral therapy along with steroids in patients who have severe and early onset of Bell’s palsy and in patients with Ramsay-Hunt syndrome. [16]
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.
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Manage with tear substitutes, lubricants, and eye protection.
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Use artificial tears during waking hours to replace diminished or absent lacrimation.
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Lubricants are used during sleep, and they may be used during waking hours if artificial tears cannot provide adequate protection.
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Eyeglasses or shields protect the eye from injury and reduce drying by decreasing direct contact of air currents with the exposed cornea.
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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.
