Treatment

Bell's palsy has a high rate of spontaneous recovery;

• complete facial nerve paralysis has a lower rate of spontaneous recovery and may benefit from treatment.
• of those who present with incomplete flaccid paralysis on clinical examination, 94% will fully recover, compared with 61% of those who present with complete flaccid paralysis (i.e., one-sided full paralysis) (1)

General measures - reassurance is important. The patient may be worried that there has been a stroke or that there will be permanent disfigurement

Treatment of Bell's palsy should be started immediately in the early stages of the condition:

• Eye protection:
  • lubricant eye drops when the eye cannot be closed or if tear secretion is inadequate; glasses for dusty or windy atmospheres. Tarsorrhaphy is unnecessary since corneal damage, when sensation is intact, is very uncommon
    
• Corticosteroids:
  • is strong evidence from randomised controlled trials and meta-analyses to support the use of oral corticosteroids within 72 hours of symptom onset to shorten the time to complete recovery in adults and improve long-term outcomes, regardless of the baseline severity of facial palsy (2,3)
    
• Antiviral agents in Bell's palsy:
  • current evidence recommends against antiviral monotherapy for Bell's palsy, with antiviral monotherapy demonstrating inferior outcomes compared with corticosteroid monotherapy and no benefit compared with placebo
  • however, antiviral therapy concomitant with corticosteroids in the acute phase of Bell’s palsy may be associated with additional clinical benefit, especially for those with severe to complete paralysis (4)
    
• Surgery - decompression of the facial nerve:
  • procedure is controversial as 85% of cases of Bell's palsy recover without treatment and, at present, those that are destined not to do so cannot be identified
  • in one meta-analysis, the rates of complete recovery from complete Bell's palsy were significantly higher in patients who underwent facial nerve decompression than in those who underwent conservative treatment, and there were no significant differences between the rates of fair and failed recovery (5)

Treatment of sequelae - if the patient has significant residual symptoms, after a reasonable time - 6-9months- a referral to a 'Facial Palsy Specialist Service' or local specialist plastic surgeon may be appropriate:

• specialist facial therapy may be of benefit and for non-resolving facial palsy or its symptoms specialist surgical techniques and botulinum toxin are potential further therapeutic options
• possible specialist management options include:
  • botulinum toxin (chemodenervation) for:
    • ipsilateral synkinesis (a secondary symptom of unresolved Bell's palsy whereby muscles start to move involuntarily, e.g. the eye closes during smiling or eating/drinking)
    • facial muscle spasms
    • contralateral overactivity of the unaffected side (hyperkinesis)
    • neuralgic pain
    • symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking)
  • reconstructive surgery (facial reanimation) to assist with eye closure, or to help recreate resting or dynamic symmetry
  • selective neurectomy involves partial nerve removal to reduce synkinetic twitches or muscle function with the aim of improving facial tone and symmetry
  • myectomy is a surgical procedure to address abnormal muscle pull in the face
• no consensus regarding the optimum dosing regimen, but options include (6):
  • prednisolone 25 mg twice daily for 10 days, or
  • prednisolone 60 mg daily for five days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred
    

• around a fifth of patients will progress from partial palsy, so these patients should also be treated (6)
  
  
• no supportive evidence has been found for use of steroids or antivirals in children with Bell's palsy (6)
  

• treatment is probably more effective before 72 hours and less effective after seven days
  
  
• Inability to close the eye on the affected side, can lead to irritation and corneal ulceration
  • requires urgent review by an ophthalmologist (7)
  • eye care advice from Facial Palsy UK states:
    • 1. Frequent instillation of artificial tear drops in the day time (at least every 2 hours) and lubricant ointment (e.g. Lacrilube) at night time.
    • 2. Ointment can be used in the day time also, but this can cause blurring of vision.
    • 3. If drops are needed more than 4 times a day then they should be PRESERVATIVE-FREE drops. Preservatives used in large quantities or over a prolonged period of time may damage the delicate cells on the surface of the eye or cause inflammation.
    • 4. Taping the eye closed at night, ensuring that the eye is fully closed, refer patient to the self-help videos on the Facial Palsy UK website. https://www.facialpalsy.org.uk/support/self-help-videos/
      • Taping the eye can be difficult to do if the eyelid skin is greasy from ointment application. Siltape http://www.advancis.co.uk/products/other-products/siltape) is a gentle tape which is kinder ot the delicate skin of the eyelid.
    • 5. General advice is to attempt voluntary eyelid closure several times an hour usually by pushing up the lower lid when blinking. Also to wear sunglasses with visors or wraparounds out of doors; to avoid bright sunlight; to avoid/minimise exposure to dry conditions such as air conditioning/central heating/car fan heaters/demisters.
    • 6. Corneal exposure with a dry eye problem may be overlooked where excessive watering is a symptom. Patients should understand that with this condition the eye may water excessively as a reflex because it is too dry and this will need careful management to avoid permanent loss of vision.
    • 7. A patient with a facial palsy who has a poor Bell's phenomenon is at an increased risk for the development of a corneal ulcer. A patient with a loss of corneal sensation is at an even greater risk.

Reference:

• 1. Peitersen E. Bell palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;(549):4-30.
• 2. Gronseth GS, Paduga R; American Academy of Neurology. Evidence-based guideline update: steroids and antivirals for Bell palsy. Neurology. 2012 (reaffirmed 2023) Nov 27;79(22):2209-13.
• 3. Madhok VB, Gagyor I, Daly F, et al. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2016;(7):CD001942.
• 4. Gagyor I, Madhok VB, Daly F, et al. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2019 Sep 5;9:CD001869.
• 5. Lee SY, Seong J, Kim YH. Clinical implication of facial nerve decompression in complete Bell's palsy: a systematic review and meta-analysis. Clin Exp Otorhinolaryngol. 2019 Nov;12(4):348-59.
• 6. Glass GE, Tzafetta K. Bell's palsy: a summary of current evidence and referral algorithm. Fam Pract. 2014 Dec;31(6):631-42
• 7. Rahman I, Sadiq SA. Ophthalmic management of facial nerve palsy: a review. Surv Ophthalmol. 2007 Mar-Apr;52(2):121-44.