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2437 pages added, reviewed or updated during the last month (last updated: 23/4/2021)

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Bell's palsy has a high rate of spontaneous recovery (1)

  • complete facial nerve paralysis has a lower rate of spontaneous recovery and may benefit from treatment.(1)
  • general measures - reassurance is important. The patient may be worried that there has been a stroke or that there will be permanent disfigurement.
  • the treatment of Bell's palsy should be started immediately in the early stages of the condition.
    • protection of the eye - lubricant eye drops when the eye cannot be closed or if tear secretion is inadequate; glasses for dusty or windy atmospheres. Tarsorrhaphy is unnecessary since corneal damage, when sensation is intact, is very uncommon

    • corticosteroids - short, rapidly tapered course of high dose prednisolone is effective in reducing the incidence and/or severity of denervation (Williamson I G, Whelan TR (1996))
      • two more recent systematic reviews concluded that Bell's palsy could be effectively treated with corticosteroids in the first seven days, providing up to a further 17% of patients with a good outcome in addition to the 80% that spontaneously improve (2,3)

    • antiviral agents in Bell's palsy
      • treatment with antivirals seems logical in Bell's palsy because of the probable involvement of herpes viruses
      • evidence from a study of patients with severe palsies that found better recovery with combined aciclovir and prednisolone than with prednisolne alone
        • the main determinate of the difference was treatment within three days of the onset of palsy (4)
        • when treatment was delayed more than four days after the onset of symptoms, no benefit was seen (1)
        • antiviral regimens that can be used are: (1)
          • acyclovir 400 mg , five times per day for seven days
          • valacyclovir 1 g , three times per day for seven days
      • however more recent evidence has not shown benefit for antiviral therapy in this condition
        • a study has shown that early treatment with prednisolone significantly improved complete recovery at 3 and 9 months, but, aciclovir given alone or in combination with prednisolone had no added benefit (6)
        • also Engstrom et al failed to show benefit of antiviral therapy in Bell's palsy (7)
          • prednisolone shortened the time to complete recovery in patients with Bell's palsy, whereas valaciclovir did not affect facial recovery

    • surgery - decompression of the facial nerve. This procedure is controversial as 85% of cases of Bell's palsy recover without treatment and, at present, those that are destined not to do so cannot be identified

    • treatment of sequelae - if recovery has not occured after a reasonable time - 10 months - then the lesion may be considered permanent and plastic surgery should be considered to correct any deformity. Surgery to cut the tympanic nerve and prevent crocodile tears - i.e. tears from the affected eye on eating as a result of faulty reinnervation in the autonomic system may also be necessary.

Key points (5):

  • facial palsy improves after treatment with oral prednisolone
    • for people (if immunocompetent patients without specific contraindications) presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone
      • no consensus regarding the optimum dosing regimen, but options include (8):
        • prednislone 25 mg twice daily for 10 days, or
        • prednisolone 60 mg daily for five days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred

    • around a fifth of patients will progress from partial palsy, so these patients should also be treated
    • no supportive evidence has been found for use of steroids or antivirals in children with Bell's palsy
  • with respect to combined oral antiviral therapy and prednisolone in adults this review stated
    • "...there is support for the use of oral prednisolone with aciclovir in patients presenting with moderate to severe facial palsy, ideally within 72 hours.."
    • however more recent studies (6,7) have not shown benefit for antiviral therapy in combination with prednisolone in this condition
  • treatment of partial Bell's palsy is controversial; a few patients don't recover if left untreated
  • treatment is probably more effective before 72 hours and less effective after seven days
  • inabilty to close the eye on the affected side, can lead to irritation and corneal ulceration.This needs consultation with an ophthalmologist or cosmetic surgeon (1)


Last reviewed 03/2021