What is the medical treatment for Bell's palsy to prevent or manage synkinesis?

Medical Treatment for Bell's Palsy-Associated Synkinesis

Combination therapy with oral corticosteroids and antivirals within 72 hours of symptom onset is the most effective approach to prevent synkinesis in Bell's palsy patients. 1, 2

Initial Treatment to Prevent Synkinesis

• Oral corticosteroids should be prescribed within 72 hours of symptom onset as first-line treatment for Bell's palsy patients 16 years and older 3, 4
• Recommended corticosteroid regimens include:
  • Prednisolone 50 mg daily for 10 days, or
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 3, 4
• Adding an antiviral to corticosteroid therapy may specifically reduce rates of synkinesis (abnormal facial muscle movements due to misdirected nerve regrowth) 1, 2
• Recommended antiviral regimens include:
  • Valacyclovir 1 g three times daily for 7 days, or
  • Acyclovir 400 mg five times daily for 10 days 1

Management of Established Synkinesis

• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited 1, 5
• Botulinum toxin injections are effective for treating established synkinesis to improve facial symmetry 6
• Botulinum toxin can be administered to:
  • Paralyze the ipsilateral orbicularis oculi
  • Treat contralateral forehead rhytides
  • Address depressor anguli oris dysfunction
  • Manage blepharospasm and muscle tightness 6
• Multiple botulinum toxin sessions (approximately four monthly injections) may be required for optimal results 6

Surgical Options for Persistent Synkinesis

• For patients with persistent synkinesis and facial asymmetry despite medical management, surgical options may include:
  • Ipsilateral brow lift
  • Division of the contralateral frontal branch
  • Contralateral tarsorrhaphy to equalize palpebral fissures
  • Bilateral upper blepharoplasty 6

Follow-up and Monitoring

• Patients should be reassessed or referred to a facial nerve specialist if:
  • New or worsening neurologic findings develop
  • Ocular symptoms develop
  • Incomplete facial recovery persists 3 months after initial symptom onset 3, 4
• Early identification and management of synkinesis can improve outcomes and quality of life 3

Efficacy of Treatment Approaches

• Combination therapy with valacyclovir and prednisone has shown significantly better outcomes compared to no treatment, with 87.5% complete recovery versus 68% in untreated patients 7
• Elderly patients particularly benefit from combination therapy, with studies showing 100% recovery rates in treated patients over 60 years versus only 41.7% in untreated controls 7
• Patients with established synkinesis report improvements in facial symmetry, ability to go out in public, and feelings of self-worth after botulinum toxin treatment 6

Important Considerations

• Treatment should be initiated within 72 hours of symptom onset for maximum effectiveness 3, 4
• Antiviral therapy alone is ineffective and not recommended 4, 1
• Eye protection is essential for patients with impaired eye closure to prevent corneal damage 3, 4
• The American Academy of Otolaryngology-Head and Neck Surgery notes that further research is needed to better establish the efficacy of different physical therapy treatment modalities on synkinesis 5