Bell Palsy Treatment & Management

Surgical options include facial nerve decompression, subocularis oculi fat (SOOF) lift, implantable devices placed into the eyelid, tarsorrhaphy, transposition of the temporalis muscle, facial nerve grafting, and direct brow lift.

In the author’s experience, surgical repair by using a combination of procedures tailored to the patients’ clinical findings works well for improving symptoms and exposure. Most patients who have had severe corneal exposure due to lagophthalmos with or without paralytic ectropion received a combination of lateral tarsal strip placement, SOOF lift, and gold-weight implantation. Patients without severe exposure have received a single procedure or combinations of procedures.

Decompression of facial nerve

Surgery to decompress the facial nerve is controversial when performed in patients with complete Bell palsy that has not responded to medical therapy and with greater than 90% axonal degeneration, as shown on facial nerve electromyography (EMG) within 3 weeks of the onset of paralysis.^{[49, 19]} The problem must be localized with magnetic resonance imaging (MRI); then, the surgeon can decide if the maxillary segment should be decompressed externally or if the labyrinthine segment and geniculate ganglion should be decompressed with a middle-fossa craniotomy.

Patients with a poor prognosis, identified by facial nerve testing or persistent paralysis, appear to benefit the most from surgical intervention. However, studies have been mixed as far as benefit from surgery.^[50]

A study compared a cohort of patients with degeneration greater than 90% who underwent middle-fossa decompression with a cohort of similar patients who chose not to pursue surgical decompression. The surgical group exhibited a House-Brackmann grade I or II in 91% of the cases. The nonsurgical group had a poor result in 58% of the patients, with a House-Brackmann grade III or IV at 7 months. This study also demonstrated that best results were obtained if the decompression was attempted within 14 days after the onset of paralysis.^[51]

Subocularis oculi fat lift with lateral tarsal strip procedure

The SOOF lift is designed to lift and suspend the midfacial musculature. The SOOF is deep to the orbicularis oculi muscle and superficial to the periosteum below the inferior orbital rim. Lifting the SOOF may also elevate the upper lip and the angle of the mouth to improve facial symmetry. A SOOF lift is commonly done in conjunction with a lateral tarsal strip procedure to tighten the eyelid.^[52]

A lateral tarsal strip procedure is performed to correct horizontal lower-lid laxity and to improve apposition of the lid to the globe. First, lateral canthotomy and cantholysis is performed. Then, the anterior lamella is removed, and the lateral tarsal strip is shortened and attached to the periosteum at the lateral orbital rim.

Implants in eyelid

Implantable devices have been used to restore dynamic lid closure in cases of severe, symptomatic lagophthalmos. These procedures are best for patients with poor Bell phenomenon and decreased corneal sensation. Gold or platinum weights, a weight-adjustable magnet, or palpebral springs can be inserted into the eyelids. Pretarsal gold-weight implantation is most commonly performed. The weight allows the upper eyelid to close with gravity when the levator palpebrae are relaxed. Therefore, patients must sleep with their head slightly elevated.

The implants are inert and composed of 99.99% pure gold or platinum. Sizes range from 0.6-1.8 g. They are easily removed if nerve function returns. Complications include migration of the implant, inflammation, allergic reaction, or extrusion.

Tarsorrhaphy

Tarsorrhaphy decreases horizontal lid opening by fusing the eyelid margins together to improve support of the precorneal lake of tears and to improve coverage of the eye during sleep. The procedure can be done in the office and is particularly suitable for patients who are unable or unwilling to undergo other surgery. It can be completed as either a temporary or a permanent measure. Permanent tarsorrhaphy is done if nerve recovery is not expected.

Tarsorrhaphy can be performed laterally, centrally, or medially. The lateral procedure is most common; however, it can restrict the monocular temporal visual field. Central tarsorrhaphy offers good corneal protection, but it occludes vision and can be cosmetically unacceptable. Medial or paracentral tarsorrhaphy is performed lateral to the lacrimal puncta and can offer good lid closure without substantially affecting the visual field.

Transposition of temporalis

Transposition of the temporalis muscle can be used to reanimate the face and to provide lid closure by using the fifth cranial nerve. Strips from the muscle and fascia are placed in the upper and lower lids as an encircling sling. Patients initiate movement by chewing or clenching their teeth.

Facial nerve grafting or hypoglossal-facial nerve anastomosis

Reinnervation of the facial nerve by means of facial nerve grafting or hypoglossal-facial nerve anastomosis can be used in cases of clinically significant permanent paralysis to help restore relatively normal function to the orbicularis oculi muscle or eyelids.

Direct brow lift

Brow ptosis is repaired with a direct brow lift. Care should be taken in the presence of corneal decompensation because lifting the brow can cause worsening of lagophthalmos, especially if lid closure is poor. A gold-weight implant can be placed or lower-lid resuspension can be performed simultaneously to prevent this complication.

If the initial impression based on the history and physical examination is not Bell palsy, then consultation with a neurologist or otolaryngologist is needed. For example, consultation with an otolaryngologist should be made for the patient who has facial palsy and pain and in whom the ear, nose, and throat examination does not show auricular vesicles (as in Ramsay Hunt syndrome). These patients should be evaluated for malignancy or other structural lesion of the facial nerve.

If the paralysis persists for several months, consultation with a neurologist or otolaryngologist should be sought. An evaluation with an otolaryngologist may be indicated for patients with a prolonged course, for the consideration of surgical decompression of the facial nerve.

Patients who report persistent dry eye or painful eye should be referred to an ophthalmologist.

An evaluation by a specialist in infectious disease may be indicated if results of laboratory studies are positive for Lyme disease, syphilis, or HIV infection.

If the paralysis is not resolved or is progressing to complete paralysis, a thorough neurologic and head, eyes, ears, nose, and throat (HEENT) examination should be performed to rule out neoplastic causes of facial nerve palsy.

The patient should be monitored if the initial EMG shows the involved facial muscles to have less than 25% of the function of the normal side.

If the residual paralysis is severe, the patient should be referred for counseling.

Because persons with true Bell palsy generally have an excellent prognosis, and because spontaneous recovery is fairly common, treatment of Bell palsy is still controversial. The goals of treatment are to improve facial nerve (seventh cranial nerve) function and reduce neuronal damage.

Many issues must be addressed in treating patients with Bell palsy. The most important consideration is the onset of symptoms. Treatment may be considered for patients who have the onset of paralysis within 1-4 days of the initial office visit.

Patients with Bell palsy frequently present to the ED. The role of the ED clinician consists of the following:

• Initiate appropriate treatment.
• Protect the eye.
• Arrange appropriate medical follow-up care.

The American Academy of Neurology (AAN) published a practice parameter in 2001 stating that steroids are probably effective and acyclovir (with prednisone) is possibly effective for treatment of Bell palsy. Any recommendation on facial decompression surgery had insufficient evidence.

A variety of nonpharmacologic measures have been used to treat Bell palsy, including physical therapy (eg, facial exercises^[33] and neuromuscular retraining^[34] ) and acupuncture.^[35] No adverse effects of these treatments have been reported. Reviews suggest that physical therapy may result in faster recovery and reduced sequelae, but further randomized controlled trials are needed to confirm any benefit.

The most widely accepted treatment for Bell palsy is corticosteroids. However, the use of steroids is still controversial because most patients recover without treatment. Antiviral agents have also been studied in this setting, as have combinations of the 2 types of drugs.

Corticosteroids

Many trials have been carried out to study the efficacy of prednisone in Bell palsy. In 1972, for example, Adour et al conducted a large, controlled clinical trial that found that 89% of patients treated with prednisone had full recovery compared with 64% of patients treated with placebo.^[36]

This study and other early studies have shown conflicting results using steroids in treating Bell palsy,^[37] and they have been limited in their size. However, 3 recent randomized, controlled trials showed significant improvement in outcomes when prednisolone was started within 72 hours of symptom onset.^{[3, 4, 38]} Based on these 3 studies, steroids should be strongly considered to optimize outcomes. Once the decision to use steroids is made, the consensus is to start immediately.

One of these 3 recent studies, a double-blind, randomized trial from Scotland involving 551 patients with Bell palsy recruited within 72 hours of the onset of symptoms, demonstrated that early treatment with prednisolone significantly improved the chances of complete recovery at 3 and 9 months.^[3] In contrast, acyclovir given alone did not show any significant difference in the rate of facial recovery compared to placebo, and there was no additional benefit from combining acyclovir and prednisolone compared to prednisolone alone.

A larger double-blind, controlled trial showed that prednisolone significantly shortened the time to complete recovery, whereas valacyclovir did not affect facial recovery compared to placebo.^[4]

The recommended dose of prednisone for the treatment of Bell palsy is 1 mg/kg or 60 mg/d for 6 days, followed by a taper, for a total of 10 days. Caution should be used in patients with tuberculosis, immunocompromise, pregnancy, an active infection, sarcoidosis, sepsis, peptic ulcer disease, diabetes mellitus, renal or hepatic dysfunction, or malignant hypertension.

High-dose steroids (>120 mg/d of prednisone) have been safely used to treat Bell palsy in patients with diabetes^{[39, 40]} ; however, optimal dosing has not been established. Caution should be given in these cases due to the risk of hyperglycemia.

Antiviral agents

Evidence evaluating the efficacy of antiviral medicines in Bell palsy has shown limited benefit,^{[41, 28]} with 3 recent randomized controlled trials showing no benefit.^{[3, 4, 38]} However, there is evidence to suggest a large percentage of Bell palsy cases may result from a viral infection.^{[16, 42]} Therefore, antiviral agents may be reasonable in certain situations.

The AAN guidelines suggest that the use of acyclovir for the treatment of Bell palsy is only possibly effective and that this agent alone is not effective in facial recovery. The Scottish study cited earlier suggested that prednisolone, and not acyclovir, is useful for facial recovery in Bell palsy.^[3]

A Cochrane review analyzed 7 studies (1987 patients) from 1966-2008 looking at the efficacy of antivirals in the complete recovery from Bell palsy. In their review, antivirals showed no significant benefit over placebo in the rate of incomplete recovery (relative risk [RR], 0.88; 95% confidence interval [CI], 0.65-1.18).^[43]

Acyclovir (Zovirax) is administered at a dosage of 400 mg orally 5 times a day for 10 days. Evidence supports herpes simplex virus (HSV) as a major cause of Bell palsy; if varicella zoster virus (VZV) is suspected, higher doses may be needed (800 mg orally 5 times a day).

Valacyclovir (Valtrex), 500 mg orally twice a day for 5 days, may be used instead of acyclovir. Although it is more expensive, it may be associated with better compliance. If VZV is the cause of Bell palsy, higher doses may be needed (1000 mg orally 3 times a day). Because of increased cost and increased risk of side effects with higher doses, valacyclovir cannot be routinely recommended at this time.

Corticosteroid-antiviral combinations

A prospective randomized trial with 101 patients comparing prednisone and acyclovir demonstrated that the prednisone group had a better clinical recovery.^[44] In another prospective, randomized trial with 99 patients, prednisone monotherapy was compared with the combination of prednisone and acyclovir. This study demonstrated that combination therapy was more effective in preventing nerve degeneration as measured by electrodiagnostic tests.^[45]

A Japanese randomized, prospective study of 221 patients with Bell palsy showed significant improvement in facial function using both prednisone and valacyclovir therapy as compared with those who used prednisone alone. This improvement was noted in those who had severe to complete facial palsy.^[12]

Quant et al conducted a meta-analysis of published studies from 1984 to January 2009 that showed no improved benefit (with respect to degree of facial muscle recovery in patients with Bell palsy) with corticosteroids plus antivirals as compared to corticosteroids alone (odds ratio 1.50; 95% confidence interval, 0.83-2.69).^[46] Six trials (representing pooled data of 1145 patients) were examined and included 574 patients who received corticosteroids alone and 571 patients who received corticosteroids and antiviral agents.

Quant et al suggest that the routine use of antivirals is not warranted; however, future studies should improve diagnostic efforts to identify herpes virus as a potential etiology. Additionally, newer antiviral agents may prove more beneficial than older antiviral agents used in the studies analyzed to date.^[46]

Contrary to the Quant et al and Cochrane meta-analyses, de Almeida et al found that antiviral agents, when combined with corticosteroids, were associated with greater risk reduction of borderline significance than were corticosteroids alone (relative risk, 0.75; 95% CI, 0.56-1.00).^[47] Their meta-analysis examined 18 trials including 2786 patients. If antivirals are to be initiated, they should be done so in conjunction with corticosteroids. Future studies will be needed to determine which population will most benefit from antiviral therapy.

Whether to use prednisone alone or combination therapy is left to the discretion of the treating physician.

It is universally accepted that eye care is imperative in Bell palsy. The patient’s eye is at risk for drying, corneal abrasion, and corneal ulcers.

In most cases, topical ocular lubrication (with artificial tears during the day and lubricating ophthalmic ointment at night, or occasionally ointment day and night) is sufficient to prevent the complications of corneal exposure.^[48] Punctal plugs may be helpful if dryness of the cornea is a persistent problem.

Occluding the eyelids by using tape or by applying a patch for 1 or 2 days may help to heal corneal erosions. Care must be taken to prevent worsening the abrasion with the tape or a patch by ensuring that the eyelid is securely closed. Clear plastic wrap, cut to 8 X 10 cm and applied with generous amounts of ointment as a nighttime occlusive bandage, may be required.

External eyelid weights are available to improve mechanical blink. The weights are attached to the upper lid with an adhesive and are available in different skin tones.

Lower-lid ectropion or droop can temporarily be helped by applying tape below the lid margin in the center of the lower lid; pull the lid laterally and upward to anchor on the orbital rim.

Botulinum toxin can be injected transcutaneously or subconjunctivally at the upper border of the tarsus and aimed at the levator muscle to produce complete ptosis and to protect the cornea.^[25] Botulinum toxin may help in relaxing the facial muscles after they have developed mass contraction, though the results are not as satisfying in patients with Bell palsy as in patients with idiopathic hemifacial spasm.