Can steroids be given to a patient with lower motor neuron (LMN) facial palsy due to mastoiditis, parotiditis, or another underlying infection, presenting with cheek swelling and pain?

Steroids in LMN Facial Palsy with Underlying Infection

Do not give steroids alone in LMN facial palsy secondary to mastoiditis, parotiditis, or other underlying infections—first treat the underlying infection with appropriate antimicrobials, then consider adding steroids only after infection control is initiated. 1, 2

Critical Distinction: This is NOT Bell's Palsy

• The presence of cheek swelling and pain with LMN facial palsy indicates an identifiable infectious cause, which by definition excludes Bell's palsy. 2, 3
• Bell's palsy is strictly a diagnosis of exclusion that can only be made when no other medical etiology is identified, and it typically does not present with significant facial swelling or erythema. 2, 3, 4
• Facial swelling and pain accompanying facial palsy should immediately raise suspicion for infectious etiologies including mastoiditis, parotiditis, Lyme disease (in endemic areas), or Ramsay Hunt syndrome rather than idiopathic Bell's palsy. 2, 4

Treatment Algorithm for Infectious Facial Palsy

Step 1: Identify and Treat the Underlying Infection First

• Mastoiditis or acute suppurative otitis media with facial palsy requires immediate antibiotic therapy as the primary intervention. 5
• In acute suppurative otitis media with facial paralysis, antibiotic therapy with or without myringotomy represents first-line management, with surgery reserved for coalescent mastoiditis or lack of clinical regression. 5
• For Lyme disease-associated facial nerve palsy (which can account for up to 25% of cases in endemic areas), intravenous ceftriaxone, cefotaxime, penicillin G, or oral doxycycline should be initiated for 14-21 days. 1, 4
• Parotiditis-related facial palsy requires treatment directed at the specific infectious agent (bacterial vs viral). 2

Step 2: Consider Adding Corticosteroids After Antimicrobial Initiation

• Once appropriate antimicrobial therapy is initiated for the underlying infection, corticosteroids may be added as adjunctive therapy to reduce facial nerve inflammation and edema. 5
• The rationale for adding steroids is that inflammation and edema of the facial nerve within the narrow temporal bone canal contribute to nerve compression regardless of the underlying cause. 1
• In acute suppurative otitis media with facial paralysis, corticosteroid therapy combined with antibiotics (with or without myringotomy) has been found effective as first-line management. 5

Step 3: Dosing Regimen When Steroids Are Used

• If steroids are added after infection control is initiated, use prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper. 1
• Moderate or low doses of steroids may be sufficient for acute facial palsy, as high doses have not demonstrated superior clinical outcomes. 6
• Initiate steroid therapy as early as possible once antimicrobials are started, ideally within 72 hours of facial palsy onset for maximum benefit. 1

Special Considerations for Lyme Disease

• For Lyme disease-associated facial nerve palsy specifically, there is no recommendation for or against adding corticosteroids to antibiotic therapy—this represents a knowledge gap in current guidelines. 1
• However, in patients age 16 or older presenting with acute facial nerve palsy without other objective clinical or serologic evidence of Lyme disease, corticosteroid treatment should be administered within 72 hours according to standard facial palsy guidelines. 1
• In Lyme-endemic areas or with appropriate travel history, obtain Lyme serology before assuming idiopathic etiology. 2, 4

Critical Pitfalls to Avoid

• Never assume all acute facial weakness is idiopathic Bell's palsy—approximately 30% of cases have identifiable causes requiring different management. 2, 4
• Do not give steroids as monotherapy without addressing the underlying infection, as this may worsen outcomes by suppressing immune response while the infection progresses. 1, 5
• Do not delay antimicrobial therapy to obtain imaging or additional testing if clinical presentation strongly suggests infectious etiology (mastoiditis, parotiditis). 5
• Bilateral facial palsy should never be accepted as idiopathic and requires investigation for Lyme disease, sarcoidosis, or Guillain-Barré syndrome. 1, 4
• Assess all other cranial nerves—involvement of additional cranial nerves excludes peripheral facial nerve pathology and suggests brainstem or central pathology. 2, 4

Mandatory Eye Protection

• Regardless of steroid use, immediately implement eye protection measures including lubricating ophthalmic drops, ophthalmic ointment, and eye taping or patching to prevent permanent corneal damage from incomplete eye closure. 3