What is the appropriate management for a patient with sudden right‑sided facial palsy?

Management of Sudden Right-Sided Facial Palsy

Immediately initiate oral corticosteroids (prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days with 5-day taper) within 72 hours of symptom onset, as this increases complete recovery from 63.6% to 83% at 3 months. 1

Initial Diagnostic Assessment

First, distinguish Bell's palsy from stroke, as this determines whether the patient needs emergency stroke protocol or outpatient corticosteroid therapy:

Key Distinguishing Features

• Bell's palsy affects the entire ipsilateral face including the forehead (inability to raise eyebrow, wrinkle forehead, close eye completely), while stroke spares the forehead due to bilateral cortical innervation of upper facial muscles 1, 2

• Confirm no other neurological deficits are present - any limb weakness, sensory changes, diplopia, dysphagia, dizziness, or involvement of other cranial nerves (V, VI, VIII, IX, X, XI, XII) excludes Bell's palsy and mandates immediate stroke protocol activation and imaging 1, 2

• Verify rapid onset within 72 hours - symptom progression beyond 72 hours suggests tumor or infection rather than Bell's palsy 1, 2

Additional Clinical Features Supporting Bell's Palsy

• Ipsilateral ear or facial pain is common at presentation 2
• Taste disturbance on the anterior two-thirds of the tongue 1, 2
• Hyperacusis (increased sound sensitivity) 1, 2
• Dry eye or excessive tearing 2

Red Flags Requiring Imaging

• Bilateral facial weakness (extremely rare in Bell's palsy - consider Guillain-Barré or sarcoidosis) 1, 2
• History of head/neck cancer 1
• Isolated branch paralysis 1
• Any other cranial nerve involvement 2
• Gradual onset or recurrent episodes 2

Routine laboratory testing and imaging are NOT recommended for typical Bell's palsy presentations 2

Immediate Medical Management

Corticosteroid Therapy (Mandatory)

Prescribe oral corticosteroids immediately - this is the only treatment with strong evidence for improving outcomes:

• Prednisolone 50 mg daily for 10 days, OR 1
• Prednisone 60 mg daily for 5 days, then taper by 10 mg daily over 5 days 3

This treatment reduces the risk of late sequelae including synkinesia, autonomic disturbances, and contractures 3

Antiviral Therapy (Optional)

• Consider adding oral antivirals to corticosteroids - combination therapy shows 96.5% complete recovery versus 89.7% with steroids alone, though the benefit is modest 2
• Antivirals are mandatory if varicella-zoster virus infection is suspected (intense pain or herpes zoster sine herpete) 3

Eye Protection (Mandatory)

Implement comprehensive eye protection immediately to prevent permanent corneal damage:

• Lubricating ophthalmic drops during the day 1, 2
• Ophthalmic ointment (dexpanthenol) at night 3
• Eye taping or patching, especially at night 1, 2
• Moisture chambers 1
• Sunglasses for outdoor protection 1

Incomplete eye closure is a medical emergency requiring aggressive corneal protection 2

Prognostic Assessment

Severity Grading

Use the House-Brackmann grading system to document baseline severity 2:

• Grade 1: Normal facial function
• Grade 2: Slight weakness with normal symmetry at rest
• Grade 3: Obvious asymmetry but not disfiguring, slight forehead movement
• Grade 4: Disfiguring asymmetry, inability to close eye completely
• Grade 5: Barely perceptible motion, incomplete eye closure
• Grade 6: Complete paralysis, no movement

Electrodiagnostic Testing (For Complete Paralysis Only)

For patients with complete facial paralysis (House-Brackmann Grade 6), consider electrodiagnostic testing at 7-14 days after onset to identify those at higher risk of incomplete recovery 4:

• Electroneuronography (ENoG) measures electrical response amplitude - if the affected side shows <10% of normal side amplitude, the patient has higher risk of incomplete recovery 4
• Electromyography (EMG) provides complementary information when ENoG shows <10% function 4
• Testing before 7 days is unreliable due to ongoing Wallerian degeneration; testing after 14-21 days may be less reliable 4

Patients with incomplete paralysis (paresis) have very high likelihood of complete recovery and do not require electrodiagnostic testing 4

Follow-Up and Specialist Referral

Mandatory Reassessment Triggers

Refer to specialist or reassess urgently if: 2

• New or worsening neurologic findings develop
• Development of ocular symptoms (corneal abrasion, exposure keratitis)
• Incomplete facial recovery at 3 months
• Symptoms persist beyond 2 months 2

Surgical Decompression (Highly Selected Cases Only)

Consider surgical decompression via middle cranial fossa approach only for patients meeting ALL criteria: 5

• Complete paralysis (House-Brackmann 6/6)
• Greater than 90% degeneration on electroneurography
• Absent electromyography activity

The evidence for surgical benefit remains controversial, with lack of large trials and variable outcomes 4

Treatments NOT Recommended

• Physical therapy - no proven benefit over spontaneous recovery 2
• Acupuncture - poor quality evidence with indeterminate benefit-harm ratio 2

Expected Outcomes

Most patients (>70%) recover completely within 6 months regardless of treatment 6, but corticosteroids significantly improve this rate and reduce complications 1, 3. The 25-40% of facial palsies with identifiable causes (not Bell's palsy) require different management, emphasizing the importance of careful initial assessment 2.