Acute Peripheral Facial Palsy: Recent Guidelines and a Systematic Review of the Literature

Overview

This article by Kim and Lee, published in the Journal of Korean Medical Science in 2020, reviews recent guidelines on acute peripheral facial palsy and adds a systematic review of related trials and meta-analyses from 2011 to 2019. The most common cause is idiopathic Bell's palsy. The authors use the 2013 AAO-HNSF guideline as their framework and compare it with the AAN (2012) and Canadian (2014) guidelines. After screening more than 5,000 records they included 38 studies: 11 clinical trials, 24 systematic reviews or meta-analyses and 3 guidelines.

Assessment and testing

Facial function is graded most often with the House-Brackmann system, but the Sunnybrook system and eFACE are gaining ground. Routine laboratory tests and routine imaging are not recommended in new-onset Bell's palsy, although the Canadian guideline advises imaging to exclude a tumour when there is no improvement or weakness progresses. Electrodiagnostic tests may be considered in complete paralysis.

Treatment

Oral steroids started within 72 hours are strongly recommended for patients aged 16 and over. Antivirals alone are not recommended, and the benefit of adding an antiviral to a steroid is still debated, although it may be considered in severe cases. Eye protection is strongly recommended. Nimodipine, low-level laser therapy and other agents have been studied but the evidence is limited. Surgical decompression is not recommended by the guidelines, though recent meta-analyses suggest a benefit in complete paralysis when done early. Electrostimulation is not recommended, and evidence for acupuncture is insufficient.

Long-term problems

Synkinesis develops in about one in five patients and there is no clear best treatment. For long-standing paralysis, facial reanimation with muscle or nerve transfer is an option. Referral to a facial nerve specialist is advised for worsening signs, eye symptoms or incomplete recovery three months after onset.