Guideline sources The following summarized guidelines for the evaluation and management of Bell's palsy are prepared by our editorial team based on guidelines from the French Society of Otorhinolaryngology (SFORL 2020), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2013), and the American Academy of Neurology (AAN 2012). 1 2 3 4 4 5 5 Definition Bell's palsy, also known as idiopathic facial paralysis, is an acute-onset, isolated, unilateral, lower motor neurone facial weakness/paralysis. 4 Epidemiology The exact cause of Bell's palsy is unknown; however, reactivation of herpes virus at the geniculate ganglion of the facial nerve has been postulated. 5 Disease course https://web.pathway.md/diseases/rec9J9Kp4rg2WXZiw 1/6 6/29/23, 3:16 AM Bell's palsy Pathway The likely vascular distension, inflammation, and edema with ischemia of the facial nerve results in Bell's palsy, which presents with clinical manifestations of unilateral weakness/paralysis of upper and lower facial muscles, drooping of ipsilateral eyelids, dry eye due to inability to close eyes completely, epiphora, drooping of the corner of the mouth, ipsilateral impaired/loss of taste sensation, difficulty in eating, dribbling of saliva, altered sensation on the affected side of the face, pain in or behind the ear, hyperacusis on the affected side if stapedius muscle is involved. Spontaneous complete recovery occurs in 70-75% of untreated patients. 4 Prognosis and risk of recurrence Bell's palsy is not associated with an increased risk of mortality. 5 Calculator House-Brackmann facial paralys Guidelines 1. Screening and diagnosis Differential diagnosis: Question the diagnosis of Bell's palsy and screen for tumoral causes in patients with peripheral facial palsy progressing beyond 72 hours after onset or showing fluctuation or recurrence or bilateral involvement. A Question the diagnosis of Bell's palsy in patients with peripheral facial palsy associated with abnormal otoscopy or parotid or cervical lymph node palpation or ipsilateral hearing loss, dizziness or other neurological signs. B 2. Classification and risk stratification Severity assessment: assess the severity of facial involvement on a standardized grading system (House-Brackmann classification) for inclusion in the medical file during initial work-up of patients with Bell's palsy. B 3. Diagnostic investigations History and physical examination: As per SFORL 2020 guidelines: Perform a clinical examination to confirm the peripheral nature of the facial palsy. B https://web.pathway.md/diseases/rec9J9Kp4rg2WXZiw 2/6 6/29/23, 3:16 AM Bell's palsy Pathway Perform a complete clinical neurological and ear, nose and throat examination with otoscopy and parotid and cervical palpation in patients presenting for peripheral facial palsy. Screen for involvement of the superior and inferior facial areas and absence of autonomic-voluntary dissociation to confirm peripheral status. Attempt to rule out involvement of the somatosensory and motor central pathways and other cranial nerves by neurological examination. B As per AAO-HNSF 2013 guidelines, obtain a clinical history and perform a physical examination to identify underlying causes in patients presenting with acute-onset unilateral facial paresis or paralysis. B Laboratory studies: As per SFORL 2020 guidelines, obtain CBC and fasting glucose in patients with Bell's palsy, and possibly HbA1c in patients with diabetes. B Show 2 more As per AAO-HNSF 2013 guidelines, avoid obtaining routine laboratory testing in patients with new-onset Bell's palsy. D Diagnostic imaging: As per SFORL 2020 guidelines, obtain MRI as an emergency examination only for patients with an atypical clinical presentation. B Show 4 more As per AAO-HNSF 2013 guidelines, avoid routine diagnostic imaging for patients with new-onset Bell's palsy. D Electrodiagnostic testing: As per SFORL 2020 guidelines, do not perform electroneuromyography before day 8 to assess prognosis of patients with Bell's palsy, given the poor prognostic value of the results, which are moreover poorly reproducible. D Show 2 more As per AAO-HNSF 2013 guidelines, avoid electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis. D Audiometry: obtain audiometry in patients with Bell's palsy. B Tympanometry: assess the stapedial reflex in patients with Bell's palsy for prognostic purposes. Question the diagnosis of Bell's palsy and screen for extratemporal cervical or parotid lesions in case of persistent stapedial reflex in patients with severe peripheral facial palsy. B 4. Medical management Corticosteroids: As per SFORL 2020 guidelines: Administer prednisolone or methylprednisolone in patients with Bell's palsy as early as possible - ideally, within 72 hours. A Use one of the following regimens for corticosteroids: https://web.pathway.md/diseases/rec9J9Kp4rg2WXZiw 3/6 6/29/23, 3:16 AM Bell's palsy Pathway 1 mg/kg/day for 7-10 days 2 mg/kg/day for 10 days in severe cases (House-Brackmann grade V or VI) unless contraindicated (Expert opinion). B As per AAO-HNSF 2013 guidelines, administer oral steroids within 72 hours of symptom onset in patients 16 years of age with Bell's palsy. B As per AAN 2012 guidelines, administer steroids to patients with new-onset Bell's palsy to increase the probability of recovery of facial nerve function. A Antiviral therapy: As per SFORL 2020 guidelines: Do not offer antiviral therapy as a sole treatment for patients with Bell's palsy. D Consider antiviral therapy in addition to corticosteroids for the treatment of patients with severe Bell's palsy treated early (within 72 h). C As per AAO-HNSF 2013 guidelines: Avoid administering oral antiviral therapy alone (without corticosteroids), for patients with new- onset Bell's palsy. D Consider antiviral therapy in addition to oral corticosteroids within 72 hours of symptom onset for patients with Bell's palsy. C As per AAN 2012 guidelines, consider offering antiviral agents in combination with steroids to patients with new-onset Bell's palsy, because of the possibility of a modest increase in recovery. C 5. Nonpharmacologic interventions Eye care: As per SFORL 2020 guidelines, advise eye care including local care, nocturnal occlusion and provide patient education, as early as possible. Refer patients with painful red eye to an ophthalmologist. Perform ophthalmologic monitoring for several weeks once recovery has begun. B Implement eye protection for patients with Bell's palsy who demonstrate impaired eye closure. B Acupuncture: As per SFORL 2020 guidelines, do not offer acupuncture to patients with Bell's palsy. D As per AAO-HNSF 2013 guidelines, insufficient evidence to make a recommendation regarding acupuncture for patients with Bell's palsy. Physical therapy: insufficient evidence to make a recommendation regarding physical therapy for the treatment of Bell's palsy. Physical therapy: As per SFORL 2020 guidelines: https://web.pathway.md/diseases/rec9J9Kp4rg2WXZiw 4/6 6/29/23, 3:16 AM Bell's palsy Pathway Refer patients with severe Bell's palsy or with factors for poor recovery to a rehabilitation specialist (speech therapist or physiotherapist, with relevant qualifications). B Do not offer electrotherapy and forced exercise (chewing gum, biofeedback) to patients with Bell's palsy. D 6. Therapeutic procedures Intratympanic corticosteroids: do not offer intratympanic corticosteroids as a sole treatment for patients with Bell's palsy. D Hyperbaric oxygen therapy: do not offer hyperbaric oxygen therapy for patients with Bell's palsy. D 7. Surgical interventions Facial nerve decompression: As per SFORL 2020 guidelines, insufficient evidence to support facial nerve decompression in patients with acute Bell's palsy. I Show 4 more As per AAO-HNSF 2013 guidelines, insufficient evidence to make a recommendation regarding surgical decompression for patients with Bell's palsy. 8. Specific circumstances Patients with Ramsay-Hunt syndrome: complete a 7-day therapy with prednisolone or methylprednisolone in addition to antiviral treatment, initiated as early as possible, in patients with Ramsay-Hunt syndrome. B 9. Follow-up and surveillance Indications for specialist referral: Reassess or refer to a facial nerve specialist patients with Bell's palsy who meet any of the following criteria: new or worsening neurologic findings at any point ocular symptoms developing at any point incomplete facial recovery 3 months after initial symptom onset. B Follow-up surveillance: consider prolonged surveillance when Bell's palsy does not fully resolve to allow treatment, in order for treatment to be adapted to functional progression. C Clinical findings https://web.pathway.md/diseases/rec9J9Kp4rg2WXZiw 5/6 6/29/23, 3:16 AM Bell's palsy Pathway Symptoms Past medical history Ear pain Recent upper respiratory infection Headache Hypersensitivity to sound Ocular exam Inability to close one eye Loss of feeling in the face Lagophthalmos Loss of the taste on the front of the tongue Tearing Neurological exam Dysarthria Lower face paralysis Upper face paralysis Head and neck exam Drooling References 1. M Fieux, V Franco-Vidal, P Devic et al. French Society of ENT SFORL guidelines. Management of acute Bell's palsy. Eur Ann Otorhinolaryngol Head Neck Dis. 2020 Dec;137 6 483 488. Open 2. Baugh RF, Basura GJ, Ishii LE et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg. 2013 Nov;149 3 Suppl):S1 27. Open 3. Gronseth GS, Paduga R, . Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012 Nov 27;79 22 2209 13. Open 4. Dhruvashree Somasundara, Frank Sullivan. Management of Bell's palsy. 2017 Jun;40 3 94 97.2017 Jun;40 3 94 97. Open 5. N Julian Holland, Jonathan M Bernstein. Bell's palsy. 2014 Apr 9;2014 1204.2014 Apr 9;2014 1204. Open 6. J W House, D E Brackmann. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985 Apr;93 2 146 7. Open https://web.pathway.md/diseases/rec9J9Kp4rg2WXZiw 6/6