What is the treatment for one-sided paralysis?

Treatment for One-Sided Paralysis

The treatment for one-sided paralysis depends critically on whether the cause is facial nerve paralysis (Bell's palsy) or central nervous system injury (stroke/hemiplegia), requiring immediate assessment to exclude stroke and other identifiable causes before initiating cause-specific therapy. 1

Immediate Assessment and Differential Diagnosis

The first priority is distinguishing between peripheral facial nerve paralysis and central causes:

• Perform urgent history and physical examination to identify the pattern of weakness: Bell's palsy affects the entire ipsilateral face including forehead, while stroke spares forehead muscles and typically presents with additional neurologic deficits (extremity weakness, speech difficulties, altered mental status, dizziness, dysphagia, diplopia). 1, 2

• Assess onset timing: Bell's palsy develops acutely within 72 hours, while other causes may have gradual progression. 1, 2

• Examine all cranial nerves: Involvement of other cranial nerves excludes Bell's palsy and suggests central pathology or other serious conditions requiring neuroimaging. 1, 2

• Check for vascular risk factors: In elderly patients with hypertension, diabetes, or hyperlipidemia presenting with sixth nerve palsy (causing horizontal diplopia), vasculopathic causes are most common. 1

Treatment for Bell's Palsy (Peripheral Facial Nerve Paralysis)

Medical Management

Prescribe oral corticosteroids within 72 hours of symptom onset for patients 16 years and older—this is a strong recommendation based on evidence showing improved outcomes. 1

• Do NOT prescribe antiviral therapy alone; however, you may offer oral antivirals in addition to steroids within 72 hours. 1

• Routine laboratory testing and diagnostic imaging are NOT recommended for typical Bell's palsy presentations. 1, 2

Eye Protection (Critical)

Implement immediate eye protection for patients with impaired eye closure to prevent exposure keratitis or corneal abrasion—this is mandatory. 1, 3

• Use ocular lubricants, eye patches, or taping the eyelid closed at night. 1

• Perform thorough cranial nerve examination and laryngoscopy before and after any intervention. 1

Follow-Up and Referral

Reassess or refer to a facial nerve specialist if: 1

• New or worsening neurologic findings develop at any point
• Ocular symptoms develop at any point
• Incomplete facial recovery persists 3 months after onset 4

Most Bell's palsy patients (70-94%) recover spontaneously within 3-6 months without treatment, but 30% may have incomplete recovery requiring intervention. 1

Treatment for Central Causes (Stroke/Hemiplegia)

Acute Stroke Management

If stroke is suspected based on central pattern weakness (forehead sparing) with other neurologic deficits:

• Immediate neurological consultation and brain imaging (CT or MRI) are indicated per American Heart Association guidelines. 3

• Acute stroke protocols including thrombolysis consideration must be initiated immediately—this is time-critical. 3

Rehabilitation for Chronic Hemiplegia

For established hemiplegia after stroke or central neurologic injury:

• Rehabilitation therapy is the mainstay for chronic stage sequelae including spasticity, muscle paresis, and poor motor control. 5

• Contralateral C7 nerve transfer surgery may be considered in select adult hemiplegia patients for upper extremity functional restoration, showing both spasticity release and motor improvements in research studies. 5

• Physical therapy strategies help patients cope with communication, movement, and perception difficulties. 6

Special Considerations and Pitfalls

Infectious Causes Requiring Urgent Treatment

In elderly, diabetic, or immunocompromised patients with facial paralysis and ear symptoms, consider necrotizing otitis externa: 4

• Immediate systemic antibiotics covering Pseudomonas aeruginosa and Staphylococcus aureus are required
• Surgical debridement of necrotic tissue is necessary
• Delaying treatment can cause permanent facial nerve damage 4

Temporal Arteritis (Giant Cell Arteritis)

In elderly patients with scalp tenderness, jaw claudication, or temporal pain, immediately check erythrocyte sedimentation rate and C-reactive protein, and perform temporal artery biopsy if results suggest giant cell arteritis—this can prevent permanent visual loss. 1

Trauma-Related Paralysis

Facial nerve paralysis may present in delayed fashion 3 days after head trauma with temporal bone fractures extending into the facial canal—high-resolution CT imaging and early otolaryngology consultation are essential. 7

Common Diagnostic Errors to Avoid

• Do NOT assume Bell's palsy without excluding stroke, especially if forehead is spared or other neurologic deficits exist. 2

• Do NOT irrigate ear canals in diabetic or immunocompromised patients as this may predispose to necrotizing otitis externa. 4

• Bilateral facial paralysis is rare and should prompt investigation for Lyme disease, sarcoidosis, or Guillain-Barré syndrome rather than Bell's palsy. 2

• Do NOT perform routine imaging or labs for typical Bell's palsy, but maintain low threshold for neuroimaging if atypical features present. 1, 2