What are the grades of facial palsy and when should steroid therapy be initiated?

Grades of Facial Palsy and Timing of Steroid Therapy

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

Facial Palsy Grading System

The House-Brackmann facial nerve grading system is commonly used to assess the severity of facial palsy:

• Grade I: Normal facial function in all areas 2
• Grade II: Slight weakness noticeable on close inspection; complete eye closure with minimal effort; slight asymmetry of smile with maximal effort; synkinesis barely noticeable 2
• Grade III: Obvious but not disfiguring difference between sides; noticeable but not severe synkinesis; complete eye closure with effort; slight asymmetry of mouth with maximal effort 2
• Grade IV: Obvious weakness and/or disfiguring asymmetry; incomplete eye closure; asymmetry of mouth with maximal effort 2
• Grade V: Only barely perceptible motion; incomplete eye closure; slight movement of corner of mouth 2
• Grade VI: Complete paralysis with no movement 2

Steroid Therapy Recommendations

Timing of Steroid Initiation

• Steroids should be initiated within 72 hours of symptom onset for optimal effectiveness 1, 3
• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends oral steroids within this timeframe for patients 16 years and older 1
• 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 3
• The number needed to treat (NNT) to achieve one additional complete recovery is 6 3

Recommended Steroid Regimen

• Prednisolone 50 mg daily for 10 days OR 2
• Prednisone 60 mg daily for 5 days followed by a 5-day taper 2

Treatment Algorithm Based on Severity

For Incomplete Facial Paralysis (House-Brackmann II-IV)

1. Initiate oral steroids within 72 hours of symptom onset 1
2. Implement appropriate eye protection if eye closure is impaired 4
3. Do not perform electrodiagnostic testing 1
4. Follow up at 3 months; refer to specialist if incomplete recovery 1

For Complete Facial Paralysis (House-Brackmann V-VI)

1. Initiate oral steroids within 72 hours of symptom onset 1
2. Consider combination therapy with antivirals (optional) 1
3. Implement aggressive eye protection measures 4
4. Consider electrodiagnostic testing 1
5. Follow up at 3 months; refer to specialist if incomplete recovery 1

Eye Protection Measures

For patients with impaired eye closure, implement the following:

• Lubricating ophthalmic drops frequently throughout the day 2
• Ophthalmic ointments, particularly at night 2
• Moisture chambers using polyethylene covers for nighttime protection 2
• Eye patching or taping with proper technique to avoid corneal damage 2
• Sunglasses for outdoor protection 2

Important Considerations

• Antiviral therapy alone should NOT be prescribed for Bell's palsy 1
• Combination therapy with antivirals may offer a small additional benefit (96.5% recovery vs 89.7% with steroids alone) 2, 5
• Routine laboratory testing and diagnostic imaging are NOT recommended for initial diagnosis 1
• MRI is indicated only for atypical presentations or no recovery after 3 months 2

Recovery Expectations

• 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
• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 2
• Complete recovery typically occurs within 3-4 months for most patients 2

Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness of therapy 6
• Using antiviral therapy alone is ineffective 1
• Failing to implement eye protection can lead to corneal damage 4
• Missing subtle weakness or inadequate eye assessment can lead to missed diagnoses 2
• Failing to refer patients with incomplete recovery after 3 months 1