HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Medical Management of Acute Facial Paralysis

Antiviral Medication There is evidence to show that viral reactivation causes facial nerve inflammation and secondary ischemia. There are reports of reactivation after local dental, orofaciomax- illary, 75,76 and facial resurfacing 77 procedures or trauma. Antiviral drugs have thus been used as adjuvant treatment of acute BP. Valacyclovir, the L -valine ester prodrug of acyclovir undergoes rapid and extensive first-pass meta- bolism to acyclovir after oral administration. Oral bioavailability of valacyclovir is three- fold to fivefold higher than oral acyclovir. 78 Acyclovir is the active antiviral component. 79,80 Contraindications to antiviral therapy include liver or kidney dysfunc- tion, pregnancy, or an immunocompromised state. There is no role for antiviral monotherapy. In studies in which steroids were compared with antiviral agents, there was a clear benefit to steroids. Furthermore, ac- cording to a recent Cochrane review, 81 there was a benefit in combining antivirals with steroids when compared with steroids alone for patients with varying degrees of para- lytic severity. This study included 10 randomized controlled trials (RCTs) with 293 par- ticipants. There was a decrease in incomplete recovery rates (low-quality evidence due to heterogeneity), as well as long-term sequelae, such as motor synkinesis and crocodile tears (moderate quality evidence). 69,82 There was also no significant differ- ence in adverse events. 68,69,78 Although there is a benefit to antiviral therapy, there has not been a study evaluating the ideal dosage. The studies included in the Cochrane review include acyclovir, vala- cyclovir, or famciclovir. The dosages also range from 1.6 to 3.0 g acyclovir per day for 5 to 7 days, or 1.0 to 3.2 g valacyclovir per day for 5 to 7 days. We recommend vala- cyclovir 1 g orally, twice a day for 7 days or famciclovir 1 g orally daily for 5 days. Side effects are gastrointestinal related and include nausea, vomiting, and diarrhea. More severe but rare side effects include allergic reactions, bronchospasm, angioe- dema, and organ failure. 83 Antivirals have also not been widely studied in the pediatric population. Eye Care Patient education regarding meticulous eye care cannot be overstated. Lagophthal- mos or the inability to close the upper eyelid as well as lower eyelid ectropion leads to an inability to protect the cornea. Paralysis of the orbicularis oculi muscle leads to unopposed retraction of the levator palpebrae superioris (LPS), which is innervated by the oculomotor nerve. For these reasons, the eye does not close fully. Ocular com- plications, such as corneal abrasion, exposure keratitis, or ulceration, may result. Typically, patients complain of a dry or watery eye and the inability to blink. The lacrimal system may also be inhibited. Prophylactic eye care consists of protective glasses, frequent administration of natural tears (preservative-free artificial tears) dur- ing the day, as well as a thicker ointment during sleep. Extra protection is afforded by a moisture chamber or a plastic eye shield. Eye patching or taping may be used, with care taken that the cornea does not become exposed under the tape. Eyelid stretching exercises also aid in full closure of the eye. The upper eyelashes are grasped and pulled inferiorly over the lower eyelid. Countertension is placed supe- riorly at the midbrow to passively stretch the LPS muscle. This mechanically disrupts the myosin chain cross-linking of the LPS from the opposite orbicularis oculi muscle. The stretch is held for 30 seconds and repeated every 8 hours. 84 Poor prognostic factors for eye injury include lack of Bell phenomenon, advanced age, an only seeing eye, no resolution after 3 months, scleral irritation, a decreased corneal reflex, or pain and vision changes. These patients will benefit from further

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