What is the management of facial nerve palsy?

Management of Facial Nerve Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset for Bell's palsy patients 16 years and older to significantly improve facial nerve recovery. 1, 2

Diagnosis and Assessment

• Bell's palsy is an acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without identifiable cause, characterized by rapid onset of unilateral facial weakness involving the forehead 2
• Routine laboratory testing and diagnostic imaging are NOT recommended for initial Bell's palsy diagnosis 1, 2
• MRI with and without contrast is the imaging test of choice when indicated (atypical presentations, no recovery after 3 months, worsening symptoms) 1, 2
• Features atypical of Bell's palsy requiring imaging include: second paralysis on same side, isolated branch paralysis, other cranial nerve involvement, or no recovery after 3 months 1

First-Line Treatment

• Prescribe oral steroids within 72 hours of symptom onset for patients 16 years and older 1, 2
• Recommended regimen: prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2, 3
• Evidence shows 83% recovery at 3 months with prednisolone vs 63.6% with placebo, and 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1, 2
• Antiviral monotherapy should NOT be prescribed for Bell's palsy 1, 3

Eye Protection (Critical)

• Implement eye protection for all patients with impaired eye closure to prevent corneal damage 2, 3
• Use lubricating ophthalmic drops frequently throughout the day 2
• Apply ophthalmic ointments for more effective moisture retention, particularly at night 2
• Consider moisture chambers using polyethylene covers for nighttime protection 2
• Use eye patching or taping with caution, particularly at night 2
• Recommend sunglasses for outdoor protection 2
• Refer to ophthalmology for severe cases with risk of corneal damage 2

Special Populations

Children

• Children have better prognosis with higher rates of spontaneous recovery 1, 2
• Evidence for steroid use in children is less conclusive 1, 3
• Consider oral steroids on an individualized basis with caregiver involvement in decision-making 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours of symptom onset with individualized assessment of benefits and risks 2

Combination Therapy Considerations

• May offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset 1, 3
• Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 1, 3
• Benefit of combination therapy is small but risks are minimal 1

Physical Therapy and Rehabilitation

• Physical therapy modalities including local superficial heat therapy, massage, exercises, electrical stimulation, and biofeedback training may have a place in treatment, though evidence is limited 4
• Each modality has specific indications and should be tailored to the patient's condition 4

Surgical Management

• For cases with incomplete recovery and residual facial weakness, both static and microsurgical dynamic methods can restore facial function 5
• Surgical procedures such as hypoglossal-facial anastomosis, temporalis myoplasty, and external canthopexy are available for significant cosmetic sequelae 6
• Early surgery in Bell's palsy is generally not recommended 4

Follow-up and Monitoring

• Reassess or refer to a facial nerve specialist if:
  • New or worsening neurologic findings develop 2, 3
  • Ocular symptoms develop 2, 3
  • Incomplete facial recovery persists 3 months after initial symptom onset 1, 2, 3
• Most patients begin showing recovery within 2-3 weeks of symptom onset 2
• Complete recovery typically occurs within 3-4 months for most patients 2

Prognosis

• Approximately 70% of patients with complete paralysis recover facial function completely within 6 months 2
• Patients with incomplete paralysis have higher recovery rates, up to 94% 2, 7
• Approximately 30% of patients may experience permanent facial weakness with muscle contractures 2
• Patients with paresis (incomplete palsy) have better outcomes than those with paralysis (complete loss of function) 7

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness of therapy 1, 3
• Using antiviral therapy alone is ineffective 1, 3
• Failing to provide adequate eye protection for patients with impaired eye closure 2, 3
• Not distinguishing between paresis (incomplete palsy) and paralysis (complete loss of function) when assessing prognosis 7
• Improper eye taping technique can cause corneal abrasion 2