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Bell's palsy - Management
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What advice can I give people with Bell's palsy?

  • Reassure the person that the prognosis is good: 85% of people with Bell's palsy make a full recovery within 9 months [Sullivan et al, 2007].
  • It is important to keep the affected eye lubricated. If the cornea is exposed after attempting to close the eyes, immediate referral to an ophthalmologist is required.
  • Lubricating eye drops should be used during the day, and eye ointment used at night [DTB, 2006].
  • If the ability to close the eye at night is impaired, then people should be advised to tape the eye closed at bedtime using microporous tape.
Basis for recommendation
  • The recommendations on eye-care are based on expert opinion [DTB, 2006].
  • The most significant clinical trial [Sullivan et al, 2007] followed up people after 3 months and 9 months. Most other systematic reviews and randomized controlled trials measured outcomes after 6–9 months.

How should I manage Bell's palsy?

  • For people presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone 25 mg twice daily for 10 days. There are no data supporting the use of prednisolone in people presenting after 72 hours.
  • Aciclovir, either alone or in combination with prednisolone, is not recommended.
Basis for recommendation

The recommendation to treat Bell's palsy with prednisolone monotherapy is based on a large randomized controlled trial (n = 551) that compared prednisolone with placebo, aciclovir and combined prednisolone and aciclovir. The trial showed prednisolone to have significant benefits over the other treatments when full recovery was assessed at 3 and 9 months [Sullivan et al, 2007].

When should I refer to secondary care?

  • Refer urgently to neurology or to ear, nose, and throat (ENT) if there is:
    • Any doubt regarding the diagnosis.
    • Recurrent Bell's palsy.
    • Bilateral Bell's palsy.
  • If the cornea remains exposed after attempting to close the eyelid, refer urgently to ophthalmology.
  • If the paralysis shows no sign of improvement after 1 month, refer urgently to ENT.
  • If there is residual paralysis after 6–9 months, consider referral to a plastic surgeon with a special interest in facial reconstructive surgery.
Basis for recommendation
  • In the absence of published evidence or guidelines, these referral recommendations are based on expert opinion.

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Bell's Palsy

Age from 16 years onwards
Prednisolone tablets: 25mg twice a day
Prednisolone 5mg gastro-resistant tablets
Take five tablets twice a day for 10 days.
Supply 100 tablets.
Age: from 16 years onwards
NHS cost: £2.20
Licensed use: no - off-label indication
Patient information: The CSM has recommended that gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have received more than 40 mg daily prednisolone. During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily) and then reduced more slowly.

© NHS Institute for Innovation and Improvement