What is the treatment for facial nerve neuropathy?

Treatment of Facial Nerve Neuropathy

For Bell's palsy (idiopathic facial nerve palsy), prescribe oral corticosteroids within 72 hours of symptom onset—specifically prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper—which increases complete recovery from 63.6% to 83% at 3 months. 1

Initial Assessment and Diagnosis

The first critical step is determining whether the facial neuropathy is Bell's palsy (idiopathic) or has an identifiable cause, as this fundamentally changes management 2, 1:

• Perform a thorough history and physical examination to exclude identifiable causes such as trauma, infection (Ramsay Hunt syndrome, Lyme disease, otitis media), tumors (schwannomas, meningiomas, parotid tumors), or inflammatory conditions (sarcoidosis, multiple sclerosis) 2, 3, 4

• Confirm peripheral facial nerve involvement by documenting weakness of the forehead—this distinguishes peripheral facial palsy from central causes where forehead function is preserved 2, 1

• Grade severity using the House-Brackmann scale (1=normal to 6=complete paralysis) to establish baseline and guide prognosis 1

• Assess for associated symptoms including hyperacusis, taste disturbance on anterior two-thirds of tongue, dry eye, and periauricular pain 1, 4

When Imaging is NOT Needed

Routine imaging and laboratory testing are NOT recommended for typical Bell's palsy presentations 2, 1. Most Bell's palsy patients do not require imaging unless specific red flags are present 2.

When Imaging IS Required

Order MRI head and orbit/face/neck with and without contrast (the highest-rated imaging modality) if any of the following are present 2:

• Symptoms persist >2-4 months without recovery 2
• Atypical features: recurrent paralysis on same side, isolated branch paralysis, bilateral facial weakness, or other cranial nerve involvement 2, 1
• New or worsening neurologic findings 1
• Suspicion for tumor, infection, or inflammatory disease 2

Add high-resolution temporal bone CT (complementary to MRI) when evaluating for temporal bone fractures, cholesteatoma, chronic otitis media, or bony canal abnormalities 2

Medical Treatment Algorithm

For Adults (≥16 years) with Bell's Palsy:

1. Corticosteroids (MANDATORY within 72 hours):

• Prednisolone 50 mg daily for 10 days, OR 1
• Prednisone 60 mg daily for 5 days, then 5-day taper 1
• Evidence: 94.4% recovery at 9 months with steroids vs 81.6% with placebo 1

2. Antiviral Therapy (OPTIONAL addition to steroids):

• May offer oral antivirals (e.g., valacyclovir, acyclovir) in combination with steroids within 72 hours 1
• Never prescribe antivirals alone—they are ineffective as monotherapy 1, 4
• Combination therapy shows modest benefit: 96.5% complete recovery vs 89.7% with steroids alone 1

For Children with Bell's Palsy:

• Children have better prognosis with higher spontaneous recovery rates than adults 2, 1
• Evidence for steroid benefit in children is inconclusive 2, 1
• Consider oral steroids with caregiver involvement in shared decision-making 1

For Pregnant Women:

• Treat with oral corticosteroids within 72 hours using the same regimens as non-pregnant adults 1
• Benefits of treatment outweigh risks in most cases 1

For Ramsay Hunt Syndrome (Herpes Zoster Oticus):

• Antiviral therapy is definitely beneficial when given within 3 days of onset 4
• Combine with corticosteroids 4

For Lyme Disease-Associated Facial Palsy:

• Antibiotics are the primary treatment and have very good prognosis 4

Eye Protection (CRITICAL for All Patients with Incomplete Eye Closure)

Implement immediate eye protection to prevent corneal damage—this is non-negotiable 2, 1:

Daytime Protection:

• Lubricating ophthalmic drops frequently throughout the day 1
• Sunglasses outdoors for protection against particles and irritants 1

Nighttime Protection:

• Ophthalmic ointments for moisture retention 1
• Eye taping or patching (with careful instruction to avoid corneal abrasion) 1
• Moisture chambers using polyethylene covers 1

When to Refer to Ophthalmology:

• Severe impairment with lagophthalmos 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Persistent incomplete eye closure beyond 3 months 1

Surgical Options for Severe Cases:

• Eyelid weight implantation 1
• Tarsorrhaphy (temporary or permanent partial eyelid closure) 1
• Botulinum toxin injections 1

Follow-Up and Reassessment

Mandatory reassessment or specialist referral is required for 2, 1:

• Incomplete facial recovery at 3 months after symptom onset 1
• New or worsening neurologic findings at any point 1
• Development of ocular symptoms at any point 1

Refer to facial nerve specialist or facial plastic surgeon for patients with incomplete recovery at 3 months to discuss reconstructive options including eyelid weights, brow lifts, static/dynamic facial slings, and nerve transfers 2, 1

Electrodiagnostic Testing

• May be offered to patients with complete facial paralysis to help establish prognosis 2, 1
• NOT recommended for patients with incomplete facial paralysis 2, 1
• Testing is not useful before several days have passed 4

Therapies WITHOUT Sufficient Evidence

No recommendation can be made for the following due to poor-quality evidence 1:

• Acupuncture—poor-quality trials with indeterminate benefit-to-harm ratio 1
• Physical therapy—limited evidence consisting only of case series 1

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1
• 70% of patients with complete paralysis recover fully within 6 months 1
• 94% of patients with incomplete paralysis recover fully 1
• 30% may experience permanent facial weakness with muscle contractures 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours—effectiveness decreases significantly 1
• Prescribing antiviral therapy alone—this is ineffective 1, 4
• Failing to provide adequate eye protection—can lead to permanent corneal damage 1
• Missing atypical features—bilateral weakness, isolated branch paralysis, or other cranial nerve involvement require imaging 2, 1
• Inadequate follow-up—failing to reassess at 3 months delays access to reconstructive options 1
• Improper eye taping technique—can cause corneal abrasion; patients need careful instruction 1