Treatments for FP
Early facial weakness
When presented with the new onset of facial palsy, the two key aspects are to try and determine the cause for the weakness and then administer suitable treatment, as well as protecting the key facial structures and functions.
Diagnosing the cause:
In some circumstances the cause for facial palsy can be very clear (e.g injury to the nerve during an operation, traumatic injury to the skull etc). In most cases, however, the cause is less clear.
Bell’s palsy is the most common cause of facial palsy and tends to present as facial weakness that comes on over a few hours. If weakness develops in seconds to minutes, then a stroke may be the underlying cause. Conversely, if weakness develops over weeks or months, then consideration should be given towards a tumour or wider systemic condition of the body. The speed of onset, therefore, has an important role in guiding the medical team on which investigations to arrange. These can include blood tests and scans.
If there hasn’t been any sign of the facial weakness improving after three weeks, then that individual should be referred on to a facial palsy specialist, or ENT/neurology specialist for further investigations. If the weakness hasn’t completely resolved after three months, then referral onto a facial palsy specialist, or ENT/plastic surgeon should be undertaken.
Bell’s palsy:
Early medical intervention within three days of the symptoms starting has been shown to significantly improve the change of a full recovery in people affected by Bell’s palsy (Corticosteroids for Bell's palsy | Cochrane). The use of high dose corticosteroids (usually prednisolone) has been shown to improve the chance of complete recovery by 10%. The scientific data on this topic have shown that, for steroids to be effective, they need to be started within 72 hours of the symptom onset. A typical dosing schedule would be:
Day 1-3 = 70mg prednisolone once daily
Day 4 = 60mg
Day 5 = 50mg
Day 6 = 40mg
Day 7 = 30mg
Day 8 = 20mg
Day 9 = 10mg
Day 10 = Stop treatment
The use of anti-viral treatment in Bell’s palsy is more controversial (Antiviral treatment for Bell's palsy (idiopathic facial paralysis) - Gagyor, I - 2019 | Cochrane Library). Studies have not shown that adding anti-virals treatment to steroid treatment in the early period of Bell’s palsy delivers any improvement in the overall recovery. It can, however, be difficult to confidently distinguish between Ramsay Hunt syndrome and Bell’s palsy, so it’s often prudent for patients to receive acyclovir within the first 72 hours as a precaution. A typical dosing schedule would be:
Acyclovir 800mg orally, 5 times a day for 7 days.
Ramsay Hunt syndrome:
In patients with Ramsay Hunt syndrome, both high-dose steroids and anti-virals should be given and started within 72 hours of the onset of the symptoms. The dosing schedule would be the same as that given for Bell’s palsy.
Protecting the eye:
One of the key features of early facial palsy is an inability to close the eye. This means that the surface of the eyeball can dry out. There is then a risk that the surface of the eye can scar over leading to permanent visual loss in that eye.
It is, therefore, essential to protect the eye whilst the face remains weak. This should include:
- Regular use of eyedrops during the day. These should be used even if the eye is watering, as this is often a sign that the surface of the eye is too dry. Please see this excellent video from Facial Palsy UK that discusses eye care in more details
- Application of eye ointment (eg. Vita-POS) in the eye at night. This should be placed along the lower eyelid just before taping the eye closed. This helps to lubricate the eye over night and helps prevent excessive drying out.
- Taping the eye closed at night. This is best done with a soft silicone tape, such as Siltape to avoid irritation to the thin skin of the eyelid. Please take a look at this video from Facial Palsy UK to help guide you on how best to apply the tape.
Other measures to try include:
- Avoiding air conditioning.
- Wear glasses or sunglasses when outside on sunny or windy days.
- Keep well hydrated.
IF YOUR EYE IS BECOMING INCREASINGLY RED AND PAINFUL, PLEASE SEEK URGENT MEDICAL ATTENTION, AS OTHER INTERVENTIONS MAY BE REQUIRED TO PROTECT THE EYE SURFACE.
Supporting the mouth:
Eating and drinking can become more difficult when one side of the face is paralysed. This can include drooling of saliva/fluid/food, biting of the cheek and a loss of the ability to be able to clear food away from around the molar teeth. To help minimise drooling, aim to swallow saliva regularly, take small sips of fluids and use narrower cups to drink from. Taping of the cheek can also help to support the corner of the mouth and reduce drooling. Please see this video from Facial Palsy UK for more information.
Protecting the facial muscles:
When one side of the face suddenly becomes paralysed, the underlying muscles and soft tissues rest in an abnormal position and are also being pulled by the other, healthy side of the face. It’s, therefore, important to stretch and massage both the paralysed AND healthy side of the face to avoid permanent changes in the muscles and soft tissues that then impact their ability to return to normal once movement returns. Please see these excellent videos from Facial Palsy UK for more information on how to go about this: