What is the workup and treatment for chronic facial paralysis?

Workup and Treatment for Chronic Facial Paralysis

The workup for chronic facial paralysis should include a thorough assessment of all facial nerve branches, identification of underlying causes, and prompt referral to facial nerve specialists for patients with incomplete recovery after 3 months. 1

Diagnostic Workup

Initial Assessment

• Evaluate all facial nerve branches, including the forehead, to differentiate peripheral from central causes
• Use the House-Brackmann scale to quantify severity (grades 1-6)
• Check for vesicular lesions or other cranial nerve deficits
• Assess eye closure and corneal protection

Diagnostic Considerations

• Duration of paralysis (acute vs. chronic)
• Pattern of onset (sudden vs. gradual)
• Unilateral vs. bilateral involvement (bilateral cases warrant investigation for conditions like Guillain-Barré syndrome or Lyme disease) 1, 2
• Presence of associated symptoms (pain, hyperacusis, taste changes)

Potential Etiologies to Investigate

• Chronic otitis media (particularly with cholesteatoma) 3
• Neoplastic processes (especially with history of head and neck cancer) 4
• Traumatic injuries (including temporal bone fractures) 2
• Infectious causes (Lyme disease, HIV) 2
• Congenital conditions (Möbius syndrome) 2
• Neurological disorders (Melkersson-Rosenthal syndrome) 2

Treatment Approach

Medical Management

1. Eye Protection (Critical)

   • Artificial tears, lubricating ophthalmic drops/ointments
   • Eye patching or taping
   • Moisture chambers
   • Ophthalmology referral for severe cases with incomplete eye closure 4, 1

2. Physical Therapy

   • While the American Academy of Otolaryngology makes no formal recommendation regarding physical therapy due to limited evidence 4, it may be considered for:
     • Maintaining range of motion
     • Preventing contractures
     • Facial exercises and biofeedback

Surgical Options for Chronic Cases

For patients with incomplete recovery after 3 months, surgical interventions should be considered 4, 1:

1. Ocular Procedures

   • Eyelid weights
   • Brow lifts
   • Tarsorrhaphy

2. Facial Reanimation Procedures

   • Static slings
   • Dynamic facial slings
   • Nerve transfers or grafts
   • Muscle transfers

3. Minimally Invasive Techniques

   • Thread-lifting techniques for facial asymmetry 5
   • Chemodenervation (botulinum toxin) for synkinesis or contralateral hyperkinesis 2

Follow-up and Monitoring

• Reassess or refer to facial nerve specialist if:
  1. New or worsening neurologic findings develop at any point
  2. Ocular symptoms develop at any point
  3. Incomplete facial recovery 3 months after initial symptom onset 4, 1

Psychosocial Support

• Address psychological impact of facial paralysis
• Consider referral for counseling or support groups
• Manage depression and chronic pain through appropriate specialist referrals 4, 6

Common Pitfalls and Caveats

• Bilateral facial paralysis is rare (3% of cases) and should prompt investigation for systemic conditions 2
• Cholesteatoma presence decreases effectiveness of surgical treatment and indicates poorer prognosis 3
• Delayed intervention in cases of facial paralysis due to chronic otitis media results in worse outcomes; early surgical intervention is crucial 3
• Patients may experience significant social distress and isolation due to facial asymmetry 1, 6

The multidisciplinary approach involving otolaryngologists, ophthalmologists, facial plastic surgeons, physical therapists, and mental health professionals is essential for optimal management of chronic facial paralysis 6.