eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Bell Palsy: Treatment & Medication

Author: Craig H Zalvan, MD, Director of Laryngology, Assistant Professor of Otolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, ENT Faculty Practice
Contributor Information and Disclosures

Updated: Oct 26, 2009

Treatment

Medical Care

Although true IFP has a good recovery in 71% of cases, with or without treatment, the standard is to treat all patients who have this condition.

Current diagnostic technology cannot predict which patients will experience sequelae, which ones will progress to complete paralysis, and which ones will recover completely.

  • Glucocorticoid therapy
    • The current treatment of IFP is 20 mg of prednisone orally qid. Its effectiveness has been demonstrated by double-blind placebo-controlled studies.
    • The patients treated with corticosteroids had an improved clinical course and had fewer incidents of synkinesis and other sequelae than those treated with placebo, but a reliably good result does not always occur. However, conflicting studies that do not demonstrate as strong a significance exist. Larger trials are now underway.
    • Another study demonstrated that prednisone significantly decreased the pain associated with IFP.
    • Unless contraindications exist, patients are treated with 1 mg/kg of prednisone up to 80 mg/d for 7-10 days.
    • The earlier the treatment is instituted, the better the prognosis.
    • If the paralysis is incomplete or improving, then the dosage can be tapered rapidly. However, if progression of the paralysis is noted or if paralysis is complete, then the full dose of corticosteroid therapy should be continued for 7-10 days and then tapered off.
  • Antiviral therapy
    • Because of the recent evidence implicating HSV as the likely cause of IFP, antiviral therapy in the form of acyclovir has been added to the treatment regimen.
    • Early studies demonstrated an improved prognosis in patients treated with a combination of prednisone and acyclovir (400 mg 5 times daily), famciclovir (500 mg tid), or valacyclovir (500 mg tid). Patients also experienced improved return of volitional muscle motion with less likelihood of partial nerve degeneration.
    • However, analysis of 5 additional studies in a systematic review of the literature failed to demonstrate significant evidence of the efficacy of antiviral treatment. In patients with a known history of vesiculation, those with recent exposure to a viral infection, and in patients who are immunocompromised addition of antiviral medication may be of some benefit, especially given the low incidence of adverse reactions to these medications.
    • A recent prospective, multicenter, randomized placebo-controlled study of 221 patients found a statistically significant rate of improvement with treatment including valacyclovir (1000mg/d for 5d) and prednisolone. Another recent randomized, multicenter, controlled study failed to detect a statistically significant difference with the addition of valacyclovir; however, this study did find a 34% reactivation rate of herpes simplex virus type 1 (HSV1) or varicella-zoster virus in patients with acute onset facial paralysis. In addition, some authors have suggested that those patients with HSV1 reactivation did benefit from the addition of valacyclovir.

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.7 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, 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.

Surgical Care

Surgical decompression of the facial nerve is, at times, an option in the treatment of IFP. Because prognosis for complete recovery is very good in patients with incomplete facial paralysis, aggressive surgical therapy is not indicated. However, numerous studies have suggested a role for surgical decompression in patients with complete paralysis and electrophysiologic degeneration as demonstrated by decrease in the electroneurography amplitude of greater than 90-95%.

Controversy remains in the literature as to which surgical approach should be used. Because the primary area of pathology of the facial nerve is the labyrinthine segment and this region can be most safely and effectively decompressed by a middle fossa subtemporal craniotomy, support for the middle fossa subtemporal craniotomy approach has been considerable. The transmastoid approach, while accessing the mastoid and tympanic segments of the facial nerve, is less favored because of its limited access to the labyrinthine segment of the facial nerve. Studies have shown greater efficacy of surgical decompression with earlier intervention.

  • A recent 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.8
  • Another recent study compared two groups of patients with greater than 95% degeneration after steroid treatment. In one group, decompression was performed from the labyrinthine segment to the stylomastoid foramen using a transmastoid approach. The other group was observed. The results demonstrated a significant improvement in the recovery of facial function in the surgical group. This study also demonstrated a trend toward better recovery with earlier intervention.
  • Thus, the literature supports a role for surgical decompression either by a transmastoid or middle fossa subtemporal craniotomy approach dependent upon the clinical and surgical experience of the surgeon. The patient should be informed about the possible risks, although rare, that exist with both approaches.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Glucocorticoids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisone (Deltasone, Meticorten, Orasone, Sterapred)

Glucocorticoid absorbed readily from GI tract. It has anti-inflammatory and immune-modulating effects and profound and varied metabolic effects. Used in the treatment of idiopathic facial paralysis.

Adult

20 mg PO qid

Pediatric

Not established

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI bleeding or ulceration

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

More on Bell Palsy

Overview: Bell Palsy
Differential Diagnoses & Workup: Bell Palsy
Treatment & Medication: Bell Palsy
Follow-up: Bell Palsy
Multimedia: Bell Palsy
References
[ CLOSE WINDOW ]

References

  1. Murakami S, Mizobuchi M, Nakashiro Y, et al. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med. Jan 1 1996;124(1 Pt 1):27-30. [Medline].

  2. Kawaguchi K, Inamura H, Abe Y. Reactivation of herpes simplex virus type 1 and varicella-zoster virus and therapeutic effects of combination therapy with prednisolone and valacyclovir in patients with Bell's palsy. Laryngoscope. 2007;Jan;117(1):147-56.

  3. Stowe J, Andrews N, Wise L. Bell's palsy and parenteral inactivated influenza vaccine. Hum Vaccin. 2006;2(3):110-2.

  4. Mutsch M, Zhou W, Rhodes P, Bopp M, Chen RT, Linder T, et al. Use of the inactivated intranasal influenza vaccine and the risk of Bell's palsy in Switzerland. N Engl J Med. Feb 26 2004;350(9):896-903. [Medline].

  5. Völter C, Helms J, Weissbrich B, Rieckmann P, Abele-Horn M. Frequent detection of Mycoplasma pneumoniae in Bell's palsy. Eur Arch Otorhinolaryngol. Aug 2004;261(7):400-4. [Medline].

  6. Papaevangelou V, Falaina V, Syriopoulou V, Theodordou M. Bell's palsy associated with Mycoplasma pneumoniae infection. Pediatr Infect Dis J. Nov 1999;18(11):1024-6. [Medline].

  7. [Best Evidence] Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis. BMJ. Sep 7 2009;339:b3354. [Medline].

  8. Pulec JL. Early decompression of the facial nerve in Bell's palsy. Ann Otol Rhinol Laryngol. Nov-Dec 1981;90(6 Pt 1):570-7. [Medline].

  9. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell's palsy. Laryngoscope. Aug 1999;109(8):1177-88. [Medline].

  10. Adour KK, Byl FM, Hilsinger RL Jr, Kahn ZM, Sheldon MI. The true nature of Bell's palsy: analysis of 1,000 consecutive patients. Laryngoscope. May 1978;88(5):787-801. [Medline].

  11. Adour KK, Ruboyianes JM, Von Doersten PG, Byl FM, Trent CS, Quesenberry CP Jr. Bell's palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol. May 1996;105(5):371-8. [Medline].

  12. Adour KK, Sheldon MI, Kahn ZM. Maximal nerve excitability testing versus neuromyography: prognostic value in patients with facial paralysis. Laryngoscope. Sep 1980;90(9):1540-7. [Medline].

  13. Adour KK, Wingerd J. Idiopathic facial paralysis (Bell's palsy): factors affecting severity and outcome in 446 patients. Neurology. Dec 1974;24(12):1112-6. [Medline].

  14. Allen D, Dunn L. Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004;(3):CD001869. [Medline].

  15. Choi SH, Yoon TH, Lee KS. Blepharokymographic analysis of eyelid motion in Bell's palsy. Laryngoscope. 2007;117(2):308-12.

  16. De Diego JI, Prim MP, Madero R, Gavilan J. Seasonal patterns of idiopathic facial paralysis: a 16-year study. Otolaryngol Head Neck Surg. Feb 1999;120(2):269-71. [Medline].

  17. Fisch U. Surgery for Bell's palsy. Arch Otolaryngol. Jan 1981;107(1):1-11. [Medline].

  18. Hato N, Yamada H, Kohno H, Matsumoto S, Honda N, Gyo K. Valacyclovir and Prednisolone Treatment for Bell's Palsy: A Multicenter, Randomized, Placebo-Controlled Study. Otol Neurotol. Feb 5 2007;[Medline].

  19. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. Apr 1985;93(2):146-7. [Medline].

  20. Hughes GB, Pensak ML. Facial nerve disorders. In: Clinical Otology. 2nd ed. New York, NY: Thieme Medical Publishers;1997:367-80.

  21. Jackler RK, Brackmann DE. The acute facial palsies. In: Neurotology: Principles and Practice. St. Louis, Mo: Mosby-Year Book;1994:1291-5.

  22. Kanoh N, Nomura J, Satomi F. Nocturnal onset and development of Bell's palsy. Laryngoscope. Jan 2005;115(1):99-100. [Medline].

  23. Kress B, Griesbeck F, Stippich C, Bähren W, Sartor K. Bell palsy: quantitative analysis of MR imaging data as a method of predicting outcome. Radiology. Feb 2004;230(2):504-9. [Medline].

  24. Peitersen E. The natural history of Bell's palsy. Am J Otol. Oct 1982;4(2):107-11. [Medline].

  25. Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004;(4):CD001942. [Medline].

  26. Yanagihara N, Hato N, Murakami S, Honda N. Transmastoid decompression as a treatment of Bell palsy. Otolaryngol Head Neck Surg. Mar 2001;124(3):282-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Bell palsy, Bell's palsy, BP, acute facial paralysis, idiopathic facial paralysis, IFP, facial palsy, lower motor neuron facial paresis, lower motor neuron facial paralysis, cranial nerve VII, CN VII

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Craig H Zalvan, MD, Director of Laryngology, Assistant Professor of Otolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, ENT Faculty Practice
Craig H Zalvan, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, Medical Society of the State of New York, New York County Medical Society, Triological Society, and Voice Foundation
Disclosure: Nothing to disclose.

Medical Editor

B Viswanatha, MBBS, MS, DLO, Professor of ENT, Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute, India
B Viswanatha, MBBS, MS, DLO is a member of the following medical societies: Association of Otolaryngologists of India, Indian Medical Association, and Indian Society of Otology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.