What treatment options are available for a patient with chronic Bell's (Bell's palsy) palsy experiencing worsening symptoms?

Treatment Options for Chronic Bell's Palsy with Worsening Symptoms

For patients with chronic Bell's palsy experiencing worsening symptoms, referral to a facial nerve specialist is strongly recommended as the primary intervention. 1

Initial Assessment

When a patient with chronic Bell's palsy presents with worsening symptoms, consider:

• Duration of symptoms and pattern of deterioration
• Previous treatments received and their effectiveness
• Presence of complications such as:
  • Eye closure problems
  • Synkinesis (involuntary facial movements)
  • Facial contractures
  • Psychological impacts (depression, anxiety)
  • Chronic pain

Treatment Algorithm

First-line Management

1. Oral corticosteroids

   • Strongly recommended for acute exacerbations of Bell's palsy 2
   • Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 3
   • Most effective when initiated within 3 days of symptom worsening

2. Antiviral therapy (optional)

   • May be considered in combination with steroids 2
   • Options include:
     • Valacyclovir 1g three times daily for 7 days
     • Acyclovir 400mg five times daily for 10 days 3
   • Note: Evidence shows minimal additional benefit when combined with steroids 2

Eye Protection (Critical)

For patients with impaired eye closure:

• Artificial tears during daytime
• Lubricating ointment at night
• Taping eyelids closed if necessary 2
• Consider referral to ocular specialist for persistent eye symptoms 1

Rehabilitation Approaches

1. Physical Therapy

   • May be beneficial for patients with more severe paralysis 3
   • Particularly helpful for addressing synkinesis and improving facial symmetry 1, 4

2. Targeted Botulinum Toxin Injections

   • Effective for managing synkinesis and facial asymmetry 4
   • Should be administered by specialists experienced with facial anatomy

3. Osteopathic Manipulative Treatment

   • May provide additional benefit when combined with physical therapy 5
   • Techniques include cranial manipulative medicine, myofascial release, and soft tissue techniques

Specialist Referral Indications

Refer to a facial nerve specialist when:

• Symptoms persist beyond 3 months 2
• Incomplete recovery with residual facial weakness 1
• Development of complications (synkinesis, contractures)
• Presence of dysphagia or other functional impairments 2

Addressing Associated Complications

1. Psychological Support

   • Depression should be managed by referral to appropriate specialists 1
   • Consider psychological impact of facial asymmetry on quality of life

2. Pain Management

   • Chronic pain, though rare, should be addressed by pain specialists 1

3. Functional Considerations

   • Address issues with:
     • Speech and articulation
     • Eating and drinking
     • Nasal patency
     • Social interactions 4

Surgical Options

Selective surgical intervention may be considered for patients with:

• Severe, persistent facial weakness
• Significant functional or aesthetic concerns
• Failure to respond to medical management 4

Monitoring and Follow-up

Regular follow-up is essential to:

• Monitor recovery progress
• Identify new complications
• Adjust treatment strategies
• Provide ongoing support and reassurance

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that a multidisciplinary approach involving specialists from various disciplines has proven most effective for managing chronic Bell's palsy with persistent symptoms 4.