What is the treatment for facial palsy?

Treatment of Facial Palsy

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

Initial Diagnostic Assessment

Before initiating treatment, you must exclude identifiable causes of facial paralysis through history and physical examination 2, 1:

• Rule out trauma (temporal bone fracture, surgical injury), tumors (parotid, acoustic neuroma), infections (Lyme disease, Ramsay Hunt syndrome), and stroke 2, 1
• Distinguish central from peripheral lesions: Bell's palsy involves the forehead; central lesions (stroke) spare forehead function 1
• Assess severity using the House-Brackmann grading system (Grade 1 = normal to Grade 6 = complete paralysis) 1
• Do NOT order routine laboratory tests or imaging for typical Bell's palsy presentations 1

Primary Medical Treatment

Corticosteroid Therapy (CORNERSTONE OF TREATMENT)

Timing is critical - steroids must be initiated within 72 hours of symptom onset 1:

• Prednisolone 50 mg orally daily for 10 days OR prednisone 60 mg orally daily for 5 days, then taper over 5 days 1
• Evidence is strong: 83% recovery at 3 months with prednisolone versus 63.6% with placebo; 94.4% recovery at 9 months versus 81.6% with placebo 1
• Do NOT delay treatment beyond 72 hours - effectiveness drops significantly after this window 1

Antiviral Therapy (OPTIONAL ADJUNCT ONLY)

• Never prescribe antivirals alone - they are ineffective as monotherapy 1, 3
• May offer valacyclovir or acyclovir in combination with corticosteroids within 72 hours as an option, though added benefit is minimal 1
• If using combination therapy: valacyclovir 1000 mg three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 1

Eye Protection (MANDATORY FOR IMPAIRED EYE CLOSURE)

Implement immediately to prevent corneal damage in patients who cannot fully close the affected eye 1:

• Daytime: Lubricating drops every 1-2 hours while awake 1
• Nighttime: Ophthalmic ointment at bedtime for sustained moisture 1
• Mechanical protection: Eye taping or patching (with careful instruction to avoid corneal abrasion), sunglasses outdoors 1
• Severe cases: Consider moisture chambers or urgent ophthalmology referral 1

Special Populations

Children

• Better prognosis than adults with higher spontaneous recovery rates 1
• Steroid benefit is uncertain in pediatric patients - no high-quality pediatric trials exist 1
• May consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days with 5-day taper for severe cases, with substantial caregiver involvement in decision-making 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
• Eye protection measures are essential and safe in pregnancy 1

Follow-Up and Referral Triggers

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

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

Electrodiagnostic Testing

• Offer to patients with complete facial paralysis (not incomplete paralysis) 2, 1
• Optimal timing: 3-14 days post-onset (testing before 7 days or after 21 days is unreliable) 1
• Prognostic value: >10% nerve response amplitude indicates excellent prognosis; <10% carries up to 50% risk of incomplete recovery 1

Therapies NOT Recommended

• Antiviral monotherapy - ineffective and should never be prescribed 1
• Surgical decompression - no recommendation can be made; rarely indicated except in specialized cases 2, 1
• Acupuncture - insufficient evidence to recommend 2
• Physical therapy/electrical stimulation - insufficient evidence to recommend 2, 4

Common Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours reduces treatment effectiveness dramatically 1
• Prescribing antivirals alone is ineffective and delays appropriate steroid treatment 1
• Inadequate eye protection can lead to permanent corneal damage in patients with lagophthalmos 1
• Failing to refer at 3 months delays access to reconstructive options for incomplete recovery 1
• Missing central causes by not testing forehead function - stroke spares the forehead, Bell's palsy does not 1

Expected Recovery Timeline

• Most patients begin showing recovery 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 experience permanent facial weakness with muscle contractures 1