Bell’s Palsy and Facial Paralysis Management
Patients who have Bell’s palsy should receive oral corticosteroids within 72 hours of symptom appearance (unless the patient has contraindications to steroid treatment). Early treatment with prednisolone increases the chance of complete recovery of facial function to 82% (Aust Prescr. 2017;40:94-97). After 72 hours, “the benefit is a toss-up,” Dr. Boahene said, “but if you were to err one way or the other, I would suggest you give it.”
Explore This IssueNovember 2020
Many clinicians also prescribe antiviral agents, as the latest Cochrane review notes “a significant difference in long-term sequelae in favor of antivirals plus corticosteroids” in patients with severe Bell’s palsy (Sao Paulo Med J. 2015;133:383).
Patients who show signs of recovery within six weeks have a good prognosis, Dr. Boahene said. However, it’s important to warn patients about the possibility of synkinesis. To minimize the likelihood of the development of unwanted facial movement, Dr. Boahene recommends facial retraining exercises “as soon as the face is recovering.”
If a patient … hasn’t smiled properly in 10 years, I’ll inject lidocaine into specific tight muscles … and then show them their improved smile. If they like the results, I say, ‘Okay, then we want to do surgery to replicate what the lidocaine did. —Kofi Boahene, MD
Facial retraining—essentially, physical therapy for the face—is one of the major recent advancements in the treatment of facial palsy, Dr. Byrne said. “We’ve learned that a highly trained physical therapist who knows how to help patients with facial paralysis can provide a lot of benefit.”
Therapists teach patients how to consciously relax muscles that want to pull tight, allowing patients to gain more control of their facial expressions and, perhaps, avoid synkinesis. A 2011 Cochrane review concluded that “there is no high-quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low-quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases,” while other studies suggest that “early facial exercise may reduce recovery time, long-term paralysis, and number of chronic cases” (Cochrane Database Syst Rev. 2011; doi: 10.1002/14651858.cd006283.pub3; Aust Prescr. 2017;40:94-97).
“We believe that focused facial nerve physical therapy can improve function in patients with facial paralysis,” Dr. Banks said, although she did add that it’s difficult to study whether seeing a physical therapist early on will improve outcomes overall and prevent synkinesis. Unfortunately, it can be difficult for patients to access facial retraining; while it is available at some academic medical centers, it’s highly specialized and not readily accessible in most communities. As the healthcare system continues to move toward virtual visits, facial retraining may become a realistic option for more patients.