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 (idiopathic) or a secondary cause requiring different treatment—Bell's palsy is a diagnosis of exclusion that can only be made after ruling out stroke, tumor, infection, and trauma. 1, 2

Critical History Elements to Obtain

• Onset timing: Bell's palsy develops rapidly over <72 hours; gradual progression over days-to-weeks suggests tumor or infection 2, 3
• Forehead involvement: Complete hemifacial weakness including forehead indicates peripheral (LMN) lesion; forehead sparing suggests stroke 2, 4
• Associated symptoms:
  • Ipsilateral ear/facial pain is common in Bell's palsy 2
  • Vesicular rash in ear canal indicates Ramsay Hunt syndrome (herpes zoster) 4
  • Facial swelling/redness is atypical for Bell's palsy and suggests Lyme disease or other infection 4
  • Taste disturbance on anterior tongue, hyperacusis, or dry eye support Bell's palsy 2, 3
• Geographic/exposure history: Lyme disease accounts for 25% of facial palsy in endemic areas 4
• Trauma history: Temporal bone fracture or recent surgery 4
• Bilateral involvement: Never accept as idiopathic—investigate for Lyme disease, sarcoidosis, or Guillain-Barré syndrome 2, 4

Physical Examination Priorities

• Test all cranial nerves: Other cranial nerve deficits exclude Bell's palsy and suggest central pathology or skull base tumor 2
• Assess eye closure: Document lagophthalmos severity and Bell's phenomenon (upward eye rotation with closure attempt) to determine corneal exposure risk 3, 5
• Grade severity: Use House-Brackmann scale (Grade 1=normal to Grade 6=complete paralysis) to guide prognosis and treatment intensity 2, 3
• Examine for vesicular rash: Check ear canal and periauricular area for herpes zoster 4

Diagnostic Testing Algorithm

Do NOT order routine laboratory tests or imaging for typical Bell's palsy presentations 1, 3

Order targeted testing only if:

• Lyme-endemic area or travel history → Lyme serology 4
• Vesicular rash present → Consider herpes zoster testing 4
• Atypical features (bilateral, recurrent, isolated branch, other cranial nerves, progressive >3 weeks) → MRI with and without contrast 2, 3
• Complete paralysis → Consider electrodiagnostic testing (ENoG/EMG) at 3-14 days post-onset for prognostic information 3

Immediate Medical Management (Within 72 Hours)

Corticosteroid Therapy: MANDATORY

Prescribe oral corticosteroids immediately for all patients ≥16 years presenting within 72 hours of symptom onset 1, 3

Dosing regimen (choose one):

• Prednisolone 50 mg daily for 10 days, OR 3
• Prednisone 60 mg daily for 5 days, then taper over 5 days 3

Evidence supporting steroids:

• 83% complete recovery at 3 months with prednisolone vs 63.6% with placebo 3
• 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 3

Pediatric considerations (<16 years):

• Children have better spontaneous recovery rates (up to 94%) than adults 3
• Steroid benefit in children is unproven, but may consider for severe/complete paralysis with shared decision-making 3
• If treating: prednisolone 1 mg/kg/day (max 50-60 mg) for 5 days, then 5-day taper 3

Antiviral Therapy: OPTIONAL ADJUNCT ONLY

Never prescribe antiviral monotherapy—it is ineffective 1, 3

May offer combination therapy (antivirals + steroids) within 72 hours:

• Valacyclovir 1000 mg three times daily for 7 days, OR 3
• Acyclovir 400 mg five times daily for 10 days 3
• Evidence shows small additional benefit: 96.5% complete recovery with combination vs 89.7% with steroids alone 3

Eye Protection: MANDATORY FOR ALL PATIENTS WITH IMPAIRED EYE CLOSURE

Implement corneal protection immediately to prevent permanent corneal damage 1, 3

Daytime regimen:

• Lubricating ophthalmic drops (e.g., hydroxypropyl methylcellulose) every 1-2 hours while awake 3
• Sunglasses outdoors for wind/particle protection 3

Nighttime regimen:

• Ophthalmic ointment at bedtime for sustained moisture 3
• Eye taping or patching (with careful instruction to avoid corneal abrasion) 3
• Consider moisture chambers (polyethylene covers) for severe cases 3

Urgent ophthalmology referral if:

• Complete inability to close eye 3
• Eye pain, vision changes, redness, or discharge 3
• Signs of corneal exposure or damage 3

Special Circumstances Requiring Modified Management

If Infection Identified (Lyme Disease, Ramsay Hunt, Mastoiditis)

Treat underlying infection FIRST, then add corticosteroids 4

• Lyme disease: Doxycycline or IV ceftriaxone for 14-21 days, then may add steroids 4
• Ramsay Hunt syndrome: Valacyclovir + corticosteroids (worse prognosis than Bell's palsy) 4
• Mastoiditis/parotiditis: Appropriate antimicrobials, then consider adding steroids after infection control initiated 4

Pregnant Patients

Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 3

• Eye protection measures are safe and essential 3
• Consider combination antiviral therapy on case-by-case basis 3

Traumatic Facial Palsy (Temporal Bone Fracture)

If electrodiagnostic testing shows >90% amplitude reduction compared to contralateral side, surgical decompression may be indicated within 3-14 days 3

Mandatory Follow-Up and Reassessment

Initial Follow-Up (1-2 Weeks)

• Assess recovery trajectory 3
• Reinforce eye protection compliance 3
• Identify early complications 3

Mandatory Reassessment or Specialist Referral at 3 Months

Refer to facial nerve specialist if: 1, 3

• Incomplete facial recovery at 3 months
• New or worsening neurologic findings at any point
• Ocular symptoms developing at any point

Red Flags Requiring Immediate Reassessment

• Progressive weakness beyond 3 weeks 3
• Development of other cranial nerve deficits 2
• Bilateral facial weakness 2, 4
• Recurrent paralysis on same side 3

Long-Term Management for Incomplete Recovery (>3 Months)

Approximately 30% of patients experience permanent facial weakness requiring long-term interventions 3

Surgical Options for Persistent Lagophthalmos

• Botulinum toxin injections (temporary, lasts months) 3
• Eyelid weight implantation 3, 5
• Tarsorrhaphy (temporary or permanent partial eyelid closure) 3, 5

Facial Rehabilitation Options

• Static procedures: brow lifts, static facial slings 3
• Dynamic procedures: nerve transfers, dynamic slings 3

Psychological Support

Screen for depression and provide referral—persistent facial asymmetry causes significant psychosocial dysfunction 3

Therapies NOT Recommended

Do NOT offer the following (no proven benefit): 1, 3

• Physical therapy
• Acupuncture
• Surgical decompression (except rare traumatic cases with severe denervation)

Common Pitfalls to Avoid

• Assuming all acute facial weakness is Bell's palsy: 30% have identifiable causes requiring different management 4
• Delaying treatment beyond 72 hours: Steroid effectiveness decreases significantly after this window 3
• Prescribing antiviral monotherapy: Completely ineffective without steroids 1, 3
• Using standard methylprednisolone dose pack: Provides only 105 mg prednisone equivalent vs required 540 mg over 14 days (significant underdosing) 3
• Inadequate eye protection monitoring: Can lead to permanent corneal damage 1, 3
• Failing to refer at 3 months with incomplete recovery: Delays access to reconstructive options 3
• Missing forehead sparing: Indicates central (stroke) rather than peripheral cause 2, 4