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Facial palsy — Clinical Guidelines

Overview

Facial palsy refers to the paralysis of facial muscles, often due to damage to the facial nerve, leading to asymmetric facial expressions and potential functional impairments such as impaired eye closure. 1 2

Diagnosis

Clinical Presentation: Asymmetry in facial movements, difficulty closing the eye on the affected side, and decreased tear production.

Electrophysiologic Tests: Nerve conduction studies and electromyography (EMG) to assess nerve function and muscle activity. 2

Grading Systems: Utilization of grading systems like the House-Brackmann (H-B) and Sunnybrook Facial Grading Systems for consistent assessment of severity and recovery. 21

Management

Surgical Interventions: For severe acute or chronic cases with poor prognosis for recovery, surgical options such as facial reanimation surgeries can be considered. 1

Medications: Corticosteroids (e.g., prednisone) and antivirals (e.g., acyclovir) in cases suspected to be due to viral causes to reduce inflammation and improve recovery. 2

Physical Therapy: Kinesiotherapy, including massages, electrostimulation, and infrared light, to maintain muscle tone and prevent contractures. 2 10

Botulinum Toxin: For managing synkinesis or hyperkinetic movements post-palsy, botulinum toxin injections can be effective. 14 12

Special Populations

Pediatrics: Sedation with ketamine can be safely used for procedures like facial laceration repair in pediatric patients. 3

Elderly: Specific considerations for surgical interventions and anesthesia techniques are necessary due to increased comorbidities and potential fragility. 1 27

Key Recommendations

Surgical Referral for Severe Cases: Consider surgical intervention for severe acute or chronic facial palsy with poor prognosis for spontaneous recovery. (Evidence: Moderate 1)

Early Corticosteroid Use: Initiate corticosteroid treatment early in cases of presumed viral etiology to enhance recovery. (Evidence: Moderate 2)

Physical Rehabilitation: Incorporate kinesiotherapy and other rehabilitative measures to maintain muscle function and prevent complications. (Evidence: Expert opinion 2 10)

Botulinum Toxin for Post-Palsy Symptoms: Utilize botulinum toxin for managing synkinetic movements post-facial palsy to improve cosmetic outcomes. (Evidence: Moderate 14 12)

Anesthesia Considerations in Pediatric Patients: Employ deep sedation with ketamine safely for pediatric facial procedures requiring anesthesia. (Evidence: Strong 3)

References

1 Alberts E, Ballmaier J, Boeger D, Buentzel J, Hoffmann K, Podzimek J et al.. Surgery for facial palsy in the hands of otorhinolaryngologists: a population-based study. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2025. link 2 Natour A, Doyle E, DeDio R, Samy RN. Temporal bone fracture related facial palsy: efficacy of decompression with and without grafting. Current opinion in otolaryngology & head and neck surgery 2024. link 3 Lee JH, Woo SS, Shin SH, Kim HJ, Kim JH, Kim SH et al.. Effect of sedation using Ketamine for primary closure of pediatric facial laceration. Medicine 2022. link 4 Derakhshan A, Reny DC, Rathi VK, McCarty JC, Lindsay RW, Lee LN et al.. Otolaryngologists Trail Other Specialties in Industry Payments From Dermal Filler Companies. The Laryngoscope 2022. link 5 Decraene L, Boudewyns A, Venstermans C, Ceulemans B. Developmental unilateral facial palsy in a newborn: six cases and literature review. European journal of pediatrics 2020. link 6 Berry J, Ashley J, Jeffery S. Ophthalmological evaluation of facial burns in a regional burns centre. Burns : journal of the International Society for Burn Injuries 2020. link 7 DeJoseph LM, Pou JD. Local Anesthetic Facelift. Facial plastic surgery clinics of North America 2020. link 8 Min JH, You YH, Cho YC, Jeong WJ, Park JS, Oh SK et al.. Comparison of cosmetic appearances after facial lacerations repaired by junior residents and experts. The American journal of emergency medicine 2019. link 9 Hsieh DM, Zhong S, Tong X, Yuan C, Yang L, Yao AY et al.. A Retrospective Study of Chinese-Specific Glabellar Contraction Patterns. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2019. link 10 Sudy E, Urbina F. Unilateral acne after facial palsy. Anais brasileiros de dermatologia 2018. link 11 Wickert NM, Wong Riff KWY, Mansour M, Forrest CR, Goodacre TEE, Pusic AL et al.. Content Validity of Patient-Reported Outcome Instruments used with Pediatric Patients with Facial Differences: A Systematic Review. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2018. link 12 Lim JTE, Loh DK, Soh K, Sunga O. Efficacy and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines. Singapore medical journal 2017. link 13 Lucchetti G, De Rossi J, Gonçalves JPB, Lucchetti ALG. Peripheral Facial Palsy: Does Patients' Religiousness Matter for the Otorhinolaryngologist?. Journal of religion and health 2016. link 14 Rzany B, Fratila AA, Fischer TC, Hilton S, Pavicic T, Rothhaar A et al.. Recommendations for the best possible use of botulinum neurotoxin type a (Speywood units) for aesthetic applications. Journal of drugs in dermatology : JDD 2013. link 15 Farber N, Haik J, Weissman O, Israeli O, Winkler E, Zilinsky I. "Wet behind the ears": the postauricular training ground for local flaps. Journal of drugs in dermatology : JDD 2012. link 16 Hanke CW, Rohrich RJ, Busso M, Carruthers A, Carruthers J, Fagien S et al.. Facial Soft-Tissue Fillers: Assessing the State of the Science conference---Proceedings report. Journal of the American Academy of Dermatology 2011. link 17 van Eijk T, Braun M. A novel method to inject hyaluronic acid: the Fern Pattern Technique. Journal of drugs in dermatology : JDD 2007. link 18 de Felipe I, Del Cueto SR, Pérez E, Redondo P. Adverse reactions after nonablative radiofrequency: follow-up of 290 patients. Journal of cosmetic dermatology 2007. link 19 Weiss RA, Weiss MA, Beasley KL, Munavalli G. Autologous cultured fibroblast injection for facial contour deformities: a prospective, placebo-controlled, Phase III clinical trial. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2007. link 20 Lowe NJ. Dispelling the myth: appropriate use of poly-L-lactic acid and clinical considerations. Journal of the European Academy of Dermatology and Venereology : JEADV 2006. link 21 Kanerva M, Poussa T, Pitkäranta A. Sunnybrook and House-Brackmann Facial Grading Systems: intrarater repeatability and interrater agreement. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2006. link 22 Carniol PJ, Gentile RD. Laser facial plastic surgery for men. Facial plastic surgery : FPS 2005. link 23 Ramos-Zabala A, Pérez-Mencía MT, Fernández-García R, Cascales-Núñez MR. Anesthesia technique for outpatient facial laser resurfacing. Lasers in surgery and medicine 2004. link 24 Stephan CN. Facial approximation: globe projection guideline falsified by exophthalmometry literature. Journal of forensic sciences 2002. link 25 Watson D, Keller GS, Lacombe V, Fodor PB, Rawnsley J, Lask GP. Autologous fibroblasts for treatment of facial rhytids and dermal depressions. A pilot study. Archives of facial plastic surgery 1999. link 26 Robinson JK. Placement of the tension-bearing suture in repairing the alar facial junction. Journal of the American Academy of Dermatology 1997. link80223-x) 27 Pulec JL. Iatrogenic facial palsy: the cost. Ear, nose, & throat journal 1996. link 28 Field LM. The midline forehead island flap. The Journal of dermatologic surgery and oncology 1987. link 29 Rees TD. Facial atrophy. Clinics in plastic surgery 1976. link

Facial palsy