Bell's palsy: Treatment and prognosis in adults
- Michael Ronthal, MD
Michael Ronthal, MD
- Professor of Neurology
- Harvard Medical School
Bell's palsy is the appellation commonly used to describe an acute peripheral facial palsy of unknown cause. However, the terms "Bell's palsy" and "idiopathic facial paralysis" may no longer be considered synonymous, as herpes simplex virus activation is the likely cause of Bell's palsy in most cases. A peripheral facial palsy is a clinical syndrome of many causes, and evaluation requires more than a superficial examination.
This review will discuss the treatment and prognosis of Bell's palsy (ie, idiopathic facial nerve palsy or facial nerve palsy of suspected viral etiology). Other clinical aspects of this disorder are reviewed separately. (See "Bell's palsy: Pathogenesis, clinical features, and diagnosis in adults".)
The treatment of facial nerve palsy related to Lyme disease is discussed elsewhere. (See "Treatment of Lyme disease", section on 'Facial nerve palsy'.)
The mainstay of pharmacologic therapy for acute idiopathic facial nerve palsy (Bell's palsy) or facial nerve palsy of suspected viral etiology is early short-term oral glucocorticoid treatment. In severe acute cases, combining antiviral therapy with glucocorticoids may improve outcomes. Eye care is important for patients with incomplete eye closure (algorithm 1).
Glucocorticoid and antiviral therapy — We recommend early treatment with oral glucocorticoids for all patients with idiopathic facial nerve palsy (Bell's palsy) or facial nerve palsy of suspected viral etiology, consistent with current guidelines [1-4]. Treatment should preferably begin within three days of symptom onset. Our suggested regimen is prednisone (60 to 80 mg/day) for one week.
- Gronseth GS, Paduga R, American Academy of Neurology. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2012; 79:2209.
- Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg 2013; 149:S1.
- Schwartz SR, Jones SL, Getchius TS, Gronseth GS. Reconciling the clinical practice guidelines on Bell's palsy from the AAO-HNSF and the AAN. Otolaryngol Head Neck Surg 2014; 150:709.
- de Almeida JR, Guyatt GH, Sud S, et al. Management of Bell palsy: clinical practice guideline. CMAJ 2014; 186:917.
- de Almeida JR, Al Khabori M, Guyatt GH, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA 2009; 302:985.
- Quant EC, Jeste SS, Muni RH, et al. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis. BMJ 2009; 339:b3354.
- van der Veen EL, Rovers MM, de Ru JA, van der Heijden GJ. A small effect of adding antiviral agents in treating patients with severe Bell palsy. Otolaryngol Head Neck Surg 2012; 146:353.
- Turgeon RD, Wilby KJ, Ensom MH. Antiviral treatment of Bell's palsy based on baseline severity: a systematic review and meta-analysis. Am J Med 2015; 128:617.
- Gagyor I, Madhok VB, Daly F, et al. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2015; :CD001869.
- Madhok VB, Gagyor I, Daly F, et al. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2016; 7:CD001942.
- Adour KK, Ruboyianes JM, Von Doersten PG, et al. Bell's palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol 1996; 105:371.
- Antunes ML, Fukuda Y, Testa JR. [Clinical treatment of Bell's palsy: comparative study among valaciclovir plus deflazacort, deflazacort and placebo]. Acta AWHO 2000; 19:68.
- Kawaguchi K, Inamura H, Abe Y, et al. Reactivation of herpes simplex virus type 1 and varicella-zoster virus and therapeutic effects of combination therapy with prednisolone and valacyclovir in patients with Bell's palsy. Laryngoscope 2007; 117:147.
- Hato N, Yamada H, Kohno H, et al. Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol 2007; 28:408.
- Sullivan FM, Swan IR, Donnan PT, et al. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med 2007; 357:1598.
- Yeo SG, Lee YC, Park DC, Cha CI. Acyclovir plus steroid vs steroid alone in the treatment of Bell's palsy. Am J Otolaryngol 2008; 29:163.
- Engström M, Berg T, Stjernquist-Desatnik A, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol 2008; 7:993.
- Berg T, Bylund N, Marsk E, et al. The effect of prednisolone on sequelae in Bell's palsy. Arch Otolaryngol Head Neck Surg 2012; 138:445.
- 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; 126:336.
- Gilden DH, Tyler KL. Bell's palsy--is glucocorticoid treatment enough? N Engl J Med 2007; 357:1653.
- Joseph SS, Joseph AW, Smith JI, et al. Evaluation of Patients with Facial Palsy and Ophthalmic Sequelae: A 23-Year Retrospective Review. Ophthalmic Epidemiol 2017; :1.
- Holland NJ, Weiner GM. Recent developments in Bell's palsy. BMJ 2004; 329:553.
- Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2011; :CD006283.
- McAllister K, Walker D, Donnan PT, Swan I. Surgical interventions for the early management of Bell's palsy. Cochrane Database Syst Rev 2013; :CD007468.
- 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; 56:830.
- Yanagihara N, Hato N, Murakami S, Honda N. Transmastoid decompression as a treatment of Bell palsy. Otolaryngol Head Neck Surg 2001; 124:282.
- Knox GW. Treatment controversies in Bell palsy. Arch Otolaryngol Head Neck Surg 1998; 124:821.
- Fisch U. Prognostic value of electrical tests in acute facial paralysis. Am J Otol 1984; 5:494.
- Sunderland S. Nerve and Nerve Injuries, 2nd ed, Churchill Livingstone, London 1978.
- House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985; 93:146.
- Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg 1996; 114:380.
- Chee GH, Nedzelski JM. Facial nerve grading systems. Facial Plast Surg 2000; 16:315.
- Berg T, Jonsson L, Engström M. Agreement between the Sunnybrook, House-Brackmann, and Yanagihara facial nerve grading systems in Bell's palsy. Otol Neurotol 2004; 25:1020.
- Coulson SE, Croxson GR, Adams RD, O'Dwyer NJ. Reliability of the "Sydney," "Sunnybrook," and "House Brackmann" facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis. Otolaryngol Head Neck Surg 2005; 132:543.
- Marsk E, Bylund N, Jonsson L, et al. Prediction of nonrecovery in Bell's palsy using Sunnybrook grading. Laryngoscope 2012; 122:901.
- Peitersen E. The natural history of Bell's palsy. Am J Otol 1982; 4:107.
- Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002; :4.
- Jabor MA, Gianoli G. Management of Bell's palsy. J La State Med Soc 1996; 148:279.
- CAWTHORNE T, HAYNES DR. Facial palsy. Br Med J 1956; 2:1197.
- Boddie HG. Recurrent Bell's palsy. J Laryngol Otol 1972; 86:117.
- Hallmo P, Elverland HH, Mair IW. Recurrent facial palsy. Arch Otorhinolaryngol 1983; 237:97.
- Pitts DB, Adour KK, Hilsinger RL Jr. Recurrent Bell's palsy: analysis of 140 patients. Laryngoscope 1988; 98:535.
- McGregor JA, Guberman A, Amer J, Goodlin R. Idiopathic facial nerve paralysis (Bell's palsy) in late pregnancy and the early puerperium. Obstet Gynecol 1987; 69:435.
- Eviston TJ, Croxson GR, Kennedy PG, et al. Bell's palsy: aetiology, clinical features and multidisciplinary care. J Neurol Neurosurg Psychiatry 2015; 86:1356.
- Hadlock TA, Greenfield LJ, Wernick-Robinson M, Cheney ML. Multimodality approach to management of the paralyzed face. Laryngoscope 2006; 116:1385.
- Ito H, Ito H, Nakano S, Kusaka H. Low-dose subcutaneous injection of botulinum toxin type A for facial synkinesis and hyperlacrimation. Acta Neurol Scand 2007; 115:271.
- Nava-Castañeda A, Tovilla-Canales JL, Boullosa V, et al. Duration of botulinum toxin effect in the treatment of crocodile tears. Ophthal Plast Reconstr Surg 2006; 22:453.
- Douglas RS, Gausas RE. A systematic comprehensive approach to management of irreversible facial paralysis. Facial Plast Surg 2003; 19:107.
- Labbé D, Bénateau H, Bardot J. [Surgical procedures for labial reanimation in facial paralysis]. Ann Chir Plast Esthet 2002; 47:580.
- Jowett N, Hadlock TA. Contemporary management of Bell palsy. Facial Plast Surg 2015; 31:93.