treatment

Last edited 04/2023 and last reviewed 04/2023

Bell's palsy has a high rate of spontaneous recovery (1)

  • complete facial nerve paralysis has a lower rate of spontaneous recovery and may benefit from treatment.(1)

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

  • the treatment of Bell's palsy should be started immediately in the early stages of the condition.
    • protection of the eye - 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 - short, rapidly tapered course of high dose prednisolone is effective in reducing the incidence and/or severity of denervation (2,3)

    • antiviral agents in Bell's palsy
      • consult expert advice - antiviral treatment in combination with a corticosteroid may be of small benefit (4)


    • surgery - decompression of the facial nerve. This 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

    • 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 (7):
        • 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

Key points:

  • Bell's palsy is facial nerve paralysis of unknown cause. Left untreated, 70-75% of patients make a full recovery (5) .

  • facial palsy improves after treatment with oral prednisolone
    • early treatment with prednisolone increases the chance of complete recovery of facial function to 82% (5)
      • eleven people need to be treated for one extra complete recovery at six months
    • for people (if immunocompetent patients without specific contraindications) presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone
      • no consensus regarding the optimum dosing regimen, but options include (4):
        • prednislone 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

  • inabilty to close the eye on the affected side, can lead to irritation and corneal ulceration
    • requires urgent review by an ophthalmologist (1)
    • 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/
      • 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:

Related pages:

crocodile tears

Bell's palsy (use of steroid therapy)