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

Management of Sudden Right-Sided Facial Palsy

Immediate Diagnostic Assessment

Start oral 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 if Bell's palsy is confirmed—this increases complete recovery from 64% to 83% at 3 months. 1, 2

Distinguish Bell's Palsy from Stroke (Critical First Step)

• Examine forehead function immediately: Bell's palsy affects the entire ipsilateral face including the forehead, whereas stroke spares forehead movement due to bilateral cortical innervation of upper facial muscles. 1
• Check for additional neurological deficits: Any limb weakness, sensory loss, diplopia, dysphagia, or involvement of cranial nerves V-XII excludes Bell's palsy and mandates immediate stroke workup. 1
• Verify rapid onset: Symptoms developing within 72 hours strongly favor Bell's palsy; gradual evolution suggests neoplastic or infectious causes. 1

Red Flags Requiring Imaging (MRI with/without contrast)

• Bilateral facial weakness (consider Guillain-Barré or sarcoidosis) 1
• History of head/neck malignancy 1
• Isolated branch paralysis or other cranial nerve involvement 1
• Gradual onset or recurrent episodes 1
• Progressive weakness beyond 3 weeks 2

Corticosteroid Therapy (Mandatory Within 72 Hours)

Prednisolone 50 mg once daily for 10 days OR prednisone 60 mg once daily for 5 days followed by 10 mg decrements daily started within 72 hours of onset. 1, 2

• Evidence shows 83% complete recovery at 3 months with steroids versus 63.6% with placebo (NNT = 6). 1, 2
• At 9 months, recovery reaches 94.4% with steroids versus 81.6% without. 1, 2
• No benefit if started after 72 hours—do not delay treatment for diagnostic testing. 1, 2

Antiviral Therapy (Optional, Modest Benefit)

• Never prescribe antivirals alone—they are ineffective as monotherapy. 1, 2
• May add valacyclovir 1000 mg three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to steroids within 72 hours. 1, 2
• Combination therapy yields 96.5% recovery versus 89.7% with steroids alone (absolute benefit 6.8%). 1, 2
• Consider when viral etiology (varicella-zoster) is suspected or in severe cases with intense pain. 1, 3

Eye Protection (Mandatory for All Cases)

Incomplete eye closure is a medical emergency requiring aggressive corneal protection to prevent permanent damage. 1

Daytime Protection

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

Nighttime Protection

• Ophthalmic ointment (dexpanthenol or similar) at bedtime for sustained moisture 1, 2, 3
• Eye taping or patching with proper technique (improper taping can cause corneal abrasion) 1, 2
• Moisture chambers using polyethylene covers for severe cases 1, 2

Urgent Ophthalmology Referral If:

• Severe impairment with complete inability to close eye 2
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Signs of corneal exposure or damage 2

Prognostic Assessment (House-Brackmann Grading)

Apply grading at presentation to guide prognosis and testing: 1

• Grade 1-5 (incomplete paralysis): Excellent prognosis (up to 94% complete recovery); no electrodiagnostic testing needed 1, 2
• Grade 6 (complete paralysis): 70% complete recovery; consider electrodiagnostic testing at 7-14 days post-onset 1, 2

Electrodiagnostic Testing (Complete Paralysis Only)

• Perform electroneurography (ENoG) 7-14 days after onset (unreliable before day 7 or after day 21). 1
• >10% amplitude compared to contralateral side: excellent prognosis 1
• <10% amplitude with absent EMG activity: up to 50% risk of incomplete recovery; consider surgical consultation 1, 4

What NOT to Do

• Do not order routine laboratory tests or imaging for typical presentations—they delay treatment without improving outcomes. 1, 2
• Do not prescribe physical therapy—no proven benefit over spontaneous recovery. 1, 2
• Do not prescribe acupuncture—low-quality evidence with indeterminate benefit-harm ratio. 1, 2
• Do not perform electrodiagnostic testing in patients with incomplete paralysis (paresis). 1, 2

Follow-Up and Referral Triggers

Mandatory Reassessment at 3 Months

• Refer to facial nerve specialist if recovery is incomplete at 3 months. 1, 2

Urgent Reassessment at Any Time If:

• New or worsening neurological findings develop 1, 2
• Ocular complications arise (corneal abrasion, exposure keratitis) 1, 2
• Progressive weakness beyond 3 weeks 2

Surgical Decompression (Highly Selected Cases Only)

Consider middle cranial fossa decompression only when all criteria are met: 1, 4

• House-Brackmann Grade 6 (complete paralysis)

• 90% degeneration on ENoG

• Absent EMG activity
• Evidence remains controversial with no large randomized trials 1

Special Populations

Pregnancy

• Treat with oral corticosteroids within 72 hours after individualized risk-benefit assessment. 1, 2
• Eye protection measures are essential and safe. 2

Diabetes

• Diabetes is not a contraindication to corticosteroids. 2
• Monitor blood glucose every 2-4 hours during first few days of steroid therapy. 2
• Adjust diabetes medications proactively; consider adding NPH insulin with morning steroid dose. 2

Children

• Better prognosis than adults with higher spontaneous recovery rates. 1, 2
• Steroid benefit in children is less conclusive; consider on individualized basis with caregiver involvement. 2

Expected Outcomes

• More than 70% of patients recover completely within 6 months regardless of treatment. 1, 5
• Early corticosteroid therapy significantly improves recovery rates and reduces late sequelae (synkinesis, autonomic disturbances, contractures). 1, 3
• Most patients begin showing recovery within 2-3 weeks. 2, 5
• Approximately 25-40% of facial palsies have identifiable non-Bell's causes requiring alternative management. 1, 3