What is the initial management approach for a patient presenting with facial nerve palsy, assuming no known allergies or contraindications?

Facial Nerve Palsy Management

Immediate Diagnostic Assessment

The first priority is to determine whether this is Bell's palsy (a diagnosis of exclusion) or a secondary cause requiring different management—perform a focused history and physical examination to exclude stroke, trauma, tumor, infection (Lyme disease, herpes zoster), and other identifiable causes. 1, 2

Key Distinguishing Features on Examination

• Forehead involvement is critical: Bell's palsy affects the entire ipsilateral face including the forehead, while stroke spares forehead function due to bilateral cortical innervation 2, 3
• Document all cranial nerves (VII-XII) to exclude stroke and central causes—presence of other cranial nerve deficits, extremity weakness, speech difficulties, or altered mental status suggests stroke rather than Bell's palsy 2
• Assess for bilateral facial weakness, which is rare in Bell's palsy and suggests alternative diagnoses such as Lyme disease, sarcoidosis, or Guillain-Barré syndrome 2
• Grade severity using the House-Brackmann scale (Grade 1 = normal to Grade 6 = complete paralysis) to guide prognosis and treatment decisions 2, 3

Associated Features Supporting Bell's Palsy Diagnosis

• Rapid onset within 72 hours 2, 3
• Ipsilateral ear or facial pain 2
• Taste disturbance on anterior two-thirds of tongue 2
• Hyperacusis, dry eye, or sagging of mouth corner 2

Initial Medical Management

Corticosteroid Therapy (STRONG RECOMMENDATION)

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older—this is the only proven effective treatment for Bell's palsy. 1, 3

Recommended regimens: 3

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

Evidence supporting steroids: 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 3

Antiviral Therapy Considerations

Do NOT prescribe antiviral therapy alone—it is ineffective as monotherapy. 1, 3

• Combination therapy (oral antivirals + corticosteroids) may be offered as an option within 72 hours, showing 96.5% complete recovery versus 89.7% with steroids alone, though the added benefit is small 3
• If using combination therapy: valacyclovir 1000 mg three times daily for 7 days, or acyclovir 400 mg five times daily for 10 days 3

Pediatric Considerations

• Children have better prognosis with higher spontaneous recovery rates than adults 3
• Evidence for corticosteroid benefit in children is less conclusive—treatment decisions should involve substantial caregiver participation in shared decision-making 3
• If treating: prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper 3

Pregnancy Considerations

• Treat pregnant women with oral corticosteroids within 72 hours using individualized risk-benefit assessment 3
• Eye protection measures are essential and safe in pregnancy 4

Eye Protection (MANDATORY)

Implement immediate eye protection for all patients with impaired eye closure to prevent permanent corneal damage—this is non-negotiable. 1, 3

Comprehensive Eye Protection Protocol

Daytime protection: 3

• Lubricating ophthalmic drops every 1-2 hours while awake
• Sunglasses outdoors to protect against wind and foreign particles

Nighttime protection: 3

• Ophthalmic ointment at bedtime for sustained moisture retention
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion
• Consider moisture chambers using polyethylene covers for severe cases

Urgent Ophthalmology Referral Indications

• Severe impairment with complete inability to close the eye 3
• Signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 3
• Development of any ocular symptoms at any point during disease course 3

Diagnostic Testing

What NOT to Order

Do NOT obtain routine laboratory testing or diagnostic imaging for typical Bell's palsy presentations. 1, 2, 3

When Imaging IS Indicated

Order MRI with and without contrast for: 3

• Atypical presentations (bilateral weakness, isolated branch paralysis, other cranial nerve involvement)
• No recovery after 3 months
• Progressive weakness beyond 3 weeks
• Recurrent paralysis on the same side
• New or worsening neurologic findings

Electrodiagnostic Testing

Offer electroneurography (ENoG) and electromyography (EMG) only to patients with complete facial paralysis, performed 3-14 days post-onset. 3, 4

• Testing before 7 days or after 14-21 days provides unreliable prognostic information 3

• 10% nerve response amplitude indicates excellent prognosis 3

• <10% function carries up to 50% risk of incomplete recovery 3
• Do NOT perform electrodiagnostic testing in patients with incomplete paralysis 1

Traumatic Facial Nerve Palsy (Special Considerations)

Imaging and Surgical Indications

• Obtain CT temporal bone with thin sections as primary imaging for traumatic palsy to evaluate fracture patterns 4
• Absolute surgical indication: >90% amplitude reduction on ENoG compared to contralateral side—91% achieve good outcomes with surgery versus 42% with steroids alone 4
• Perform middle fossa decompression within 14 days of injury when indicated 4

Follow-Up and Reassessment

Mandatory Reassessment Timeline

Reassess or refer to facial nerve specialist at 3 months if facial recovery is incomplete. 1, 3

Urgent Reassessment Triggers (At Any Time)

• New or worsening neurologic findings 1, 3
• Development of ocular symptoms 1, 3
• Progressive weakness beyond 3 weeks 3

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks 3
• Complete recovery typically occurs within 3-4 months 3
• Patients with incomplete paralysis: up to 94% complete recovery 3
• Patients with complete paralysis: approximately 70% complete recovery within 6 months 3
• 30% may experience permanent facial weakness with muscle contractures 3

Long-Term Management for Incomplete Recovery

Reconstructive Options (After 3-6 Months)

• Static procedures: eyelid weights, brow lifts, static facial slings 3
• Dynamic procedures: nerve transfers, dynamic facial slings 3
• Tarsorrhaphy for persistent severe lagophthalmos 3, 5

Psychosocial Support

• Screen for depression in patients with persistent paralysis 3
• Address quality of life issues including difficulty expressing emotion and social stigmatization 3

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours reduces effectiveness 3
• Prescribing antiviral monotherapy is ineffective and delays appropriate treatment 1, 3
• Inadequate eye protection can lead to permanent corneal damage 1, 3
• Failing to refer at 3 months delays access to reconstructive options 3
• Missing atypical features (bilateral weakness, other cranial nerve involvement) that suggest alternative diagnoses requiring imaging 2, 3
• Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction 3