eMedicine Specialties > Ophthalmology > Neurologic Disorders

Bell Palsy: Treatment & Medication

Author: Thomas R Hedges III, MD, Director of Neuro-Ophthalmology, New England Eye Center; Professor, Departments of Neurology and Ophthalmology, Tufts University School of Medicine
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Updated: Oct 30, 2009

Treatment

Medical Care

• Systemic therapy
  • Evidence has shown that early corticosteroid use for Bell palsy improves outcome in patients, whereas antiviral therapy fails to demonstrate any significant beneficial effect. A double-blind, randomized trial of 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. 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.^4,5
  • Quant et al conducted a meta-analysis of published studies from 1984 to January 2009 to compare use of corticosteroids plus antiviral agents with corticosteroids alone on degree of facial muscle recovery in patients with Bell palsy.¹⁴ 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. The analysis showed no improved benefit for Bell palsy with use of corticosteroids plus antivirals compared with corticosteroids alone (odds ratio 1.50; 95% confidence interval [CI], 0.83-2.69; P=0.18). The authors suggest 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.
• Local therapy
  • 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.¹⁵
  • 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.
  • 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.
  • Clear plastic wrap, cut to 8 X 10 cm and applied with generous amounts of ointment as a nighttime occlusive bandage, may be required.
  • 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.
  • Punctal plugs may be helpful if dryness of the cornea is a persistent problem.
  • 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.¹¹
  • Botulinum toxin may help in relaxing the facial muscles after they have developed mass contraction, though the results are not as satisfying as in patients with Bell palsy as in patients with idiopathic hemifacial spasm.

Surgical Care

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 EMG within 3 weeks of the onset of paralysis.^16,13 The problem must be localized with 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 by way of a middle-fossa craniotomy.

• Procedures to correct lower lid droop and ectropion 
  • The suborbicularis oculi fat (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.¹⁷
  • 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.
• Procedures to correct lagophthalmos
  • 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 is 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 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. 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. The procedures can be completed as temporary or permanent measures. Permanent tarsorrhaphy is done if nerve recovery is not expected.
  • 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.
  • 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.
• 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.
• 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.

Consultations

Depending on the workup results and clinical course, consultations with the following specialists may be indicated:

• Neurologist: An evaluation with a neurologist may be indicated for patients with a prolonged course, abnormal imaging studies, or inconsistencies in the findings on neurologic examination.
• Infectious disease specialist: 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.
• Ear, nose, and throat specialist: An evaluation with an otolaryngologist may be indicated for patients with a prolonged course for the consideration of surgical decompression of the facial nerve.

Medication

The goal of pharmacotherapy is to reduce morbidity by shortening the recovery time and preventing long-term complications.^18,19

Corticosteroids

Corticosteroids may be beneficial in decreasing swelling and inflammation of the facial nerve. They have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Prednisone (Deltasone, Orasone, Sterapred)

May decrease inflammation by reversing increased capillary permeability and suppressing activity of polymorphonuclear (PMN) leukocytes.

Antiviral agents

Use of these agents is controversial, but many cases of Bell palsy may be correlated with herpes simplex infection; therefore, an antiviral may be beneficial.

Acyclovir (Zovirax)

Inhibits activity of HSV-1 and HSV-2. Use within 48 h of rash onset decreases pain and speeds resolution of cutaneous lesions. May prevent recurrent outbreaks.

Valacyclovir (Valtrex)

Prodrug rapidly converted to active drug acyclovir. More expensive than acyclovir but has more convenient dosing and better bioavailability.

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