Management of Facial Palsy in a 38-Year-Old Female

Step 1: Initial Assessment and Cause Identification

• Onset: Sudden (Bell's palsy, Ramsay Hunt) vs. progressive (tumor - must be imaged)
• Completeness: Partial vs. complete paralysis
• Associated features:
  • Vesicles on pinna/ear canal/oropharynx → Ramsay Hunt syndrome (VZV)
  • Ear discharge, chronic otitis media → otogenic cause
  • Tick exposure, rash → Lyme disease (Borrelia burgdorferi)
  • Bilateral palsy → metabolic, autoimmune, infectious (Lyme), sarcoid
  • Parotid mass → parotid tumor
  • Recent viral illness, periauricular pain → Bell's palsy (HSV-1 reactivation)
• Grading: Use the House-Brackmann grading scale (I = normal, VI = complete palsy)

At 38 years, a female is at peak incidence age for Bell's palsy (peak 15-45 years). In pregnancy, Bell's palsy is more common (especially 3rd trimester), though this patient's pregnancy status is not specified.

1. Paralysis or paresis of all muscle groups on one side of the face
2. Sudden onset
3. Absence of signs of CNS disease
4. Absence of signs of ear or CPA disease

Step 2: Investigations

• Indicated only in complete paralysis failing to improve
• Electroneurography (ENoG): perform ~10 days post onset
• If CAP decline does NOT reach 90% → excellent prognosis without surgery
• If 90% degeneration on ENoG + absent voluntary motor potentials on EMG → consider surgical decompression
• 67% of patients who reach 90% degeneration still achieve excellent outcomes

Step 3: Medical Management

A. Corticosteroids (FIRST-LINE - Most Evidence)

• Must start within 72 hours of onset for maximum benefit
• Evidence: Scottish Bell's Palsy Study showed clear benefit with prednisolone within 72 h
• A multi-institutional trial of 829 patients showed higher recovery rates and less synkinesis when steroids started within 48 hours
• Meta-analysis shows 17% better chance of complete recovery vs. untreated patients

If presenting late (>72 h but within 1 week), steroids can still be offered, though benefit is less established.

B. Antiviral Therapy (Adjunctive)

• Evidence is mixed: Cummings notes AAN 2012 found antivirals add <7% additional benefit over steroids alone
• Scott-Brown's notes the most recent Cochrane evidence supports combination therapy for reducing incomplete recovery and long-term sequelae (synkinesis, excessive tearing)
• Most ENT surgeons advocate combination therapy (steroid + antiviral)
• Particularly important if Ramsay Hunt syndrome is suspected - here antivirals are mandatory and strongly beneficial

• Prednisolone 1 mg/kg/day × 10 days
• Acyclovir 400 mg 5× daily × 10 days (or Valacyclovir 1g TDS × 7 days)

Step 4: Eye Care (URGENT - Do Not Neglect)

Over time, unopposed levator palpebrae superioris (CN III) causes upper lid shortening - patients must be taught lid-stretching exercises from the outset.

Step 5: Physical Therapy and Rehabilitation

• Facial physiotherapy/neuromuscular retraining is strongly supported
• Techniques include: biofeedback, EMG-guided exercises, mirror therapy, self-directed exercises
• Timing: Start as soon as possible and continue throughout recovery
• Particularly important for patients at risk of or with synkinesis (involuntary co-movements)
• Goal: maintain muscle tone, promote recovery, minimize synkinesis and contracture

Step 6: Surgical Management

1. Complete facial paralysis confirmed
2. ENoG showing ≥90% degeneration within 14 days of onset
3. No voluntary motor potentials on EMG

Note: Surgical decompression in Bell's palsy is NOT standard practice. Most surgeons do NOT recommend it routinely. The evidence base is limited by small trial sizes. For traumatic facial palsy, surgical indications are different.

Step 7: Management of Sequelae

Step 8: Cause-Specific Additions

Prognosis of Bell's Palsy

• 80-90% recover completely overall
• Incomplete paralysis at presentation: 95-100% full recovery
• Complete paralysis: recovery expected in ~3 months in two-thirds of patients
• No further recovery expected after 6 months
• Poor prognostic factors: complete paralysis at onset, old age, dry eye, absent taste, absent stapedius reflex, postauricular pain, diabetes mellitus, hypertension, age >60

Summary: Management Checklist

1. Confirm Bell's palsy (exclude other causes; progressive palsy → urgent MRI)
2. Start prednisolone 1 mg/kg/day within 72 hours
3. Add acyclovir/valacyclovir (combination therapy preferred by most ENT surgeons)
4. Protect the eye - artificial tears, ointment, taping, lid weight if needed
5. Refer to physiotherapy for facial neuromuscular retraining
6. Baseline bloods: glucose, BP, FBC
7. ENoG only if complete palsy - at 14 days post onset
8. Ophthalmology review if eye at risk
9. Review at 3-4 weeks: assess recovery; adjust plan
10. Long-term: manage synkinesis, consider reanimation if no recovery by 6 months