What is the appropriate management for a patient with persistent idiopathic facial palsy (Bell's palsy) two years after onset?

Management of Persistent Bell's Palsy After 2 Years

After 2 years of persistent facial palsy, the acute treatment window has long closed and you must focus on surgical reconstruction, eye protection, and psychological support—corticosteroids and antivirals are irrelevant at this stage. 1

Critical First Step: Confirm the Diagnosis

At 2 years post-onset, you must question whether this is truly idiopathic Bell's palsy. Persistent paralysis beyond the expected recovery timeline raises concern for an alternative diagnosis such as tumor, chronic infection, or systemic disease. 1, 2

• Order MRI with and without contrast immediately if not already done, as recurrent or non-recovering facial palsy mandates imaging to exclude neoplasm, schwannoma, parotid tumor, or skull-base pathology. 1, 2
• Perform a complete cranial nerve examination—any involvement of cranial nerves other than CN VII excludes Bell's palsy and indicates central or skull-base disease requiring urgent neurosurgical evaluation. 1, 2
• Review the original presentation: Was onset truly within 72 hours? Was the forehead involved? Progressive weakness beyond 3 weeks or bilateral involvement suggests an alternative diagnosis. 1, 2

Immediate Referrals Required

Refer to a facial nerve specialist or facial plastic surgeon now—the 3-month referral threshold was passed 21 months ago, and delayed referral limits reconstructive options. 1, 3

• Facial nerve specialist or facial plastic surgeon for evaluation of reconstructive procedures, including static procedures (eyelid weights, brow lifts, facial slings) or dynamic procedures (nerve transfers, free muscle flaps). 1, 3
• Ophthalmology referral for persistent lagophthalmos to prevent permanent corneal damage and consider surgical options such as tarsorrhaphy or eyelid weight implantation. 1, 3
• Psychology or psychiatry referral for screening and management of depression, as patients with persistent facial paralysis experience significant psychosocial dysfunction, stigmatization, and impaired social interaction. 1

Surgical Reconstruction Options

At 2 years, facial muscles have undergone fibroadipose metaplasia and are no longer viable targets for simple nerve reinnervation—you must transfer new healthy muscle to the face. 4, 5

For Smile Restoration:

• Temporalis muscle transposition or free gracilis muscle flap with dual innervation are the two primary options for restoring voluntary smile. 1, 5
• The choice depends on patient anatomy, surgeon expertise, and patient preference after detailed discussion of pros and cons. 5

For Eye Closure:

• Gold or titanium eyelid weight implantation is the most common procedure for persistent lagophthalmos, improving passive closure by gravity. 1, 5
• Temporalis muscle transposition (double-belly flap) can provide active closure but is more complex. 1, 5
• Tarsorrhaphy (permanent or temporary partial eyelid closure) is reserved for severe cases or when other options fail. 1, 5

For Static Symmetry:

• Brow lift corrects forehead ptosis. 1
• Fascia lata suspension or other static slings improve midface and lower face symmetry at rest. 1, 5

Ongoing Eye Protection (Until Surgical Correction)

Continue aggressive corneal protection to prevent exposure keratitis and permanent corneal damage. 1, 3

• Lubricating drops every 1–2 hours while awake to maintain hydration. 1
• Ophthalmic ointment at bedtime for sustained overnight moisture. 1
• Eye taping or patching at night with proper technique to avoid corneal abrasion. 1
• Moisture chambers (polyethylene covers) for severe exposure. 1
• Sunglasses outdoors to protect against wind, debris, and UV exposure. 1
• Seek urgent ophthalmology care for any eye pain, vision changes, redness, discharge, or increasing irritation. 1

Functional Complications to Address

Patients with 2-year persistent paralysis face multiple functional deficits requiring multidisciplinary management. 1

• Lacrimal dysfunction (dry eye) requires ongoing artificial tears and possible punctal plugs. 1
• Nasal airway obstruction from nasal valve collapse may require nasal surgery or external support. 1
• Oral incompetence (drooling, difficulty eating/drinking/speaking) may improve with static slings or dynamic reconstruction. 1
• Synkinesis (involuntary co-contraction of facial muscles) may develop during aberrant reinnervation and can be managed with botulinum toxin injections. 6

Prognosis and Expectations

At 2 years, spontaneous recovery is essentially zero—approximately 30% of Bell's palsy patients experience permanent facial weakness, and this patient is clearly in that group. 1, 4

• Facial muscles remain viable reinnervation targets for up to 2 years, meaning this patient is at the absolute limit for nerve-based reconstruction; beyond this, only free muscle transfer is effective. 4, 5
• Reconstructive surgery can significantly improve symmetry and function, but patients must understand that results will not restore completely normal facial movement. 5
• Multiple staged procedures are often required to optimize outcomes, including fine-tuning surgeries for details. 5

Common Pitfalls to Avoid

• Do not prescribe corticosteroids or antivirals—these are only effective within 72 hours of onset and have no role 2 years later. 1, 6
• Do not delay imaging—persistent paralysis beyond 3 months mandates MRI to exclude tumor or other structural pathology. 1, 2
• Do not neglect psychological impact—depression and social isolation are common and require active screening and referral. 1
• Do not assume "Bell's palsy" is the correct diagnosis—30% of facial palsies have identifiable causes requiring different management. 2
• Do not offer false hope of spontaneous recovery—at 2 years, only surgical intervention can improve function. 4, 5