Immediate Actions
The sudden onset of facial paralysis can be scary and confusing. Time is of the essence when pursuing treatment in the immediate aftermath of facial paralysis onset - ideally in the first 72 hours.
Symptoms You May Experience
Facial signs
One-sided facial droop
Can't smile symmetrically
Can't close eye on affected side
Can't raise eyebrow or wrinkle forehead
Slack, "melted" appearance of cheek
Other Symptoms
Intense headache
Extreme sensitivity to normal noise levels
Drooling or dry mouth
Metallic taste or loss of taste
Excessive tears or dry eye
Dizziness/vertigo
Ringing in ear or hearing loss
Pain in/behind ear, face, head, neck
Accidentally biting inside of cheek/lip
1. Get the Right Medications Now
Work with your provider (e.g., primary care, ER doctor) to begin a treatment regimen as soon as possible after the onset of facial paralysis and other concerns are ruled out.
HIGH-DOSE STEROIDS (ESSENTIAL)
For all Bell’s Palsy or Ramsay Hunt Syndrome patients:
A minimum of Prednisone or equivalent: 60mg daily for 5 days with another 5 day taper OR Prednisone 50 mg daily for 10 days. Both of these doses have been found to be effective at dramatically improving recovery rates. 1,2
For those with Bell’s Palsy or Ramsay Hunt Syndrome with COMPLETE paralysis:
Consideration should be given to increasing the starting dose to 80-120 mg of prednisone per day. 3,4
Why It Matters:
Reduces inflammation of facial nerve
Significantly improves recovery if taken within 3 days
Studies show this is the most effective treatment
Special considerations:
- The risks of systemic steroids include but are not limited to infection, weight gain, bone loss, anxiety, sleep problems, diabetes, high blood pressure, early cardiovascular disease, development of cataracts and/or glaucoma, skin thinning, adrenal insufficiency and avascular necrosis of the femur.
- Diabetes and High Blood Pressure: Work with your health care provider to manage blood sugars and blood pressure so you can get the full recommended dose if possible.
- Pregnant/nursing: Check with OB/GYN before starting
- Do NOT take NSAIDs (ibuprofen, aspirin, naproxen) while on steroids without provider approval
ANTIVIRAL MEDICATION (ESSENTIAL)
What you need:
Valacyclovir 1,000mg, 3 times daily for at least 7 days. It is reasonable to consider a longer initial treatment course of 21 days. 5,6
Why It Matters:
Initial treatment with antivirals has been linked to lower rates of synkinesis, one of the negative long-term effects from incomplete recovery of facial palsy
Facial palsy likely caused by reactivated herpes virus
Longer courses at a suppressive dose may prevent recurrences during recovery
Very safe medication with minimal side effects
2. Protect Your Eye Immediately
Why It Matters:
Can't blink properly = cornea exposed
Can become dry, scratched, infected
CAN CAUSE PERMANENT VISION LOSS
Daytime:
- Preservative-free eyedrops (use frequently, every 30-60 minutes)
- Must be preservative-free (preservatives toxic with frequent use)
- Keep bottles everywhere (purse, car, bedside, bathroom)
Nighttime:
- Lubricating eye ointment (thick, greasy coating)
- Moisture chamber (clear eye patch with sponge edges)
- Protects eye while you sleep, keeps moisture in
- Available online or make your own
All Day:
- Wraparound sunglasses (protect from wind, sun, debris)
- OR regular glasses/plano lenses (non-prescription)
To help your eye close:
- Place finger under your affected eye
- Look DOWN at your finger (don’t move head)
- Gently close both eyes
- Hold for count of 10
- Repeat 5-10 times
- Do this 3 times per day
Why: Counteracts Bell’s phenomenon (eyeball rolls up when trying to close)
See Eye Specialist Within Days: Ophthalmologist OR Oculoplastic surgeon
They will:
Examine cornea for damage
Assess blink function
Prescribe additional treatments if needed
Determine if surgical intervention needed (lid weights, etc.)
3. Seek Specialized Care
Why this is urgent:
Your health care provider may recommend additional steroid treatment
Early treatment minimizes synkinesis (abnormal nerve regrowth)
Who to see:
- Plastic surgeon or facial plastic surgeon with facial palsy experience
- Facial therapy specialist
- ENT specialist (otologist) with facial nerve expertise
- Neurologist specializing in facial palsy
- NOT just any ENT or general practitioner
REFERENCES
Engström, M., T. Berg, A. Stjernquist-Desatnik, S. Axelsson, A. Pitkäranta, M. Hultcrantz, M. Kanerva, P. Hanner, L. Jonsson. 2008. "Prednisolone and Valaciclovir in Bell's Palsy: a Randomised, Double-blind, Placebo-controlled, Multicentre Trial." The Lancet Neurology (11): 993–1000. DOI: 10.1016/S1474-4422(08)70221-7. PubMed PMID: 18849193.
Sullivan, F.M., I.R. Swan, P.T. Donnan, J.M. Morrison, B.H. Smith, B. McKinstry, R.J. Davenport, L.D. Vale, J.E. Clarkson, V. Hammersley, S. Hayavi, A. McAteer, K. Stewart, F. Daly. 2007. "Early Treatment with Prednisolone or Acyclovir in Bell's Palsy." The New England Journal of Medicine 18; 357 (16): 1598–607. DOI: 10.1056/NEJMoa072006. PubMed PMID: 17942873.
Fujiwara T, Namekawa M, Kuriyama A, Tamaki H. "High-dose Corticosteroids for Adult Bell's Palsy: Systematic Review and Meta-analysis." Otol Neurotol. 2019 Sep;40(8):1101–1108. doi: 10.1097/MAO.0000000000002317. PMID: 31290805.Fujiwara T, Namekawa M, Kuriyama A, Tamaki H. "High-dose Corticosteroids for Adult Bell's Palsy: Systematic Review and Meta-analysis." Otol Neurotol. 2019 Sep;40(8):1101–1108. doi: 10.1097/MAO.0000000000002317. PMID: 31290805.
Gupta KK, Balai E, Tang HT, Ahmed AA, Doshi JR. "Comparing the Use of High-Dose to Standard-Dose Corticosteroids for the Treatment of Bell's Palsy in Adults — A Systematic Review and Meta-analysis." Otol Neurotol. 2023 Apr 1;44(4):310–316. doi: 10.1097/MAO.0000000000003823. Epub 2023 Jan 28. PMID: 36706448.
Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. "A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster." N Engl J Med. 1994 Mar 31;330(13):896–900. doi: 10.1056/NEJM199403313301304. PMID: 8114860.
Berg T, Axelsson S, Engström M, Stjernquist-Desatnik A, Pitkäranta A, Kanerva M, Jonsson L. "The course of pain in Bell's palsy: treatment with prednisolone and valacyclovir." Otol Neurotol. 2009 Sep;30(6):842–6. doi: 10.1097/MAO.0b013e3181ab31c8. PMID: 19503012.