What is the initial treatment for a patient with facial nerve palsy?

Initial Treatment for Facial Nerve Palsy

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy, using either prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper. 1

Immediate Assessment and Diagnosis

Before initiating treatment, confirm the diagnosis through:

• Rapid onset verification: Symptoms must develop in less than 72 hours with unilateral facial weakness affecting both upper and lower face (including forehead) 1
• Exclusion of other causes: Rule out stroke (which spares forehead), tumor, infection (Lyme disease, herpes zoster), trauma, or other neurologic deficits through history and physical examination 2, 1
• No routine testing needed: Do not order laboratory tests or imaging for typical presentations 1

First-Line Pharmacologic Treatment

Corticosteroid Therapy (Mandatory)

Start immediately within 72 hours - this is the only treatment with strong evidence for improved outcomes:

• Prednisolone 50 mg orally daily for 10 days (preferred regimen) 1
  • OR Prednisone 60 mg orally daily for 5 days, then taper by 10 mg daily over 5 days 1, 3
• Evidence of benefit: 83% recovery at 3 months versus 63.6% with placebo; 94.4% recovery at 9 months versus 81.6% with placebo 1
• Number needed to treat = 10 to achieve one additional complete recovery 3

Antiviral Therapy (Optional)

• Do NOT prescribe antivirals alone - they are ineffective as monotherapy 1
• May offer acyclovir or valacyclovir in combination with steroids within 72 hours for severe cases, though benefit is small 1
• Mandatory only if varicella-zoster virus infection is confirmed 3

Eye Protection (Critical)

Implement immediately for all patients with impaired eye closure to prevent corneal damage:

• Daytime: Frequent lubricating eye drops (every 1-2 hours while awake) 1
• Nighttime: Ophthalmic ointment plus eye taping or moisture chamber 1, 3
• Outdoor: Sunglasses for protection from particles and wind 1
• Refer to ophthalmology if severe lagophthalmos, eye pain, vision changes, or redness develops 1

Special Population Considerations

Children

• Better prognosis than adults with higher spontaneous recovery rates 1
• Steroid benefit unproven in pediatrics - involve caregivers in shared decision-making 1
• May consider prednisolone 1 mg/kg/day (max 50-60 mg) for severe paralysis if caregivers prefer intervention 1

Pregnant Women

• Treat with corticosteroids on an individualized basis, carefully weighing benefits versus risks 1
• Eye protection remains essential 1

Common Pitfalls to Avoid

• Missing the 72-hour window: Corticosteroid effectiveness drops significantly after this timeframe 1
• Prescribing antivirals alone: This provides no benefit and delays effective treatment 1
• Inadequate eye protection: Can lead to permanent corneal damage, especially overnight 1
• Failing to assess forehead function: Central causes (stroke) spare the forehead; missing this distinction leads to inappropriate treatment 1
• Ordering unnecessary tests: Routine labs and imaging delay treatment without adding diagnostic value in typical presentations 1

Follow-Up Requirements

Reassess or refer to specialist if:

• No improvement or worsening at any point 1
• Incomplete recovery at 3 months after onset 1
• Development of eye symptoms (pain, vision changes, redness) 1
• Atypical features (bilateral palsy, isolated branch involvement, other cranial nerve deficits) 1

Expected Recovery Timeline

• Most patients begin showing improvement within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1
• Incomplete paralysis: Up to 94% complete recovery 1
• Complete paralysis: Approximately 70% complete recovery within 6 months 1
• 30% may have permanent weakness with contractures or synkinesis 1