para>Steroids should be used cautiously during pregnancy; consult with an obstetrician.
ISSUES FOR REFERRAL
Patients may need to be referred to an ear, nose, and throat specialist or a neurologist.
ADDITIONAL THERAPIES
- Physical therapy: strong evidence that physical therapy combined with drug treatment has positive effect on grade and time of recovery compared with drug treatment only (7,8 and 9)[A].
- Electrostimulation and mirror biofeedback rehabilitation have limited evidence of effect (10)[C].
- Acupuncture with strong stimulation has shown some therapeutic promise.
- Routine use of eye-protective measures for patients with incomplete eye closure is recommended (6)[A].
SURGERY/OTHER PROCEDURES
- Surgical treatment of Bell palsy remains controversial and is reserved for intractable cases.
- There is insufficient evidence to decide whether surgical intervention is beneficial or harmful in the management of Bell palsy (11)[B].
- In those cases where surgical intervention is performed, cranial nerve XII is surgically decompressed at the entrance to the meatal foramen where the labyrinthine segment and geniculate ganglion reside.
- Decompression surgery should not be performed >14 days after the onset of paralysis because severe degeneration of the facial nerve is likely irreversible after 2 to 3 weeks.
- A routine surgical decompression is not recommended (6)[B].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Patients should start steroid treatment immediately and be followed for 12 months.
- Patients who do not recover complete facial nerve function should be referred to an ophthalmologist for tarsorrhaphy.
PATIENT EDUCATION
American Academy of Family Physicians: http://www.aafp.org/afp/2007/1001/p1004.html
PROGNOSIS
- Most patients achieve complete spontaneous recovery within 2 weeks. >80% recover within 3 months.
- 85% of untreated patients will experience the first signs of recovery within 3 weeks of onset.
- 16% are left with a partial palsy, motor synkinesis, and autonomic synkinesis.
- 5% experience severe sequelae, and a small number of patients experience permanent facial weakness and dysfunction.
- Poor prognostic factors include the following:
- Age >60 years
- Complete facial weakness
- Hypertension
- Ramsay-Hunt syndrome
- The Sunnybrook and House-Brackmann facial grading systems are clinical prognostic models that identify Bell palsy patients at risk for nonrecovery at 12 months.
- Treatment with prednisolone or no prednisolone and the Sunnybrook score are significant factors for predicting nonrecovery at 1 month (12)[C].
- Patients with no improvement or progression of symptoms should be referred to ENT (6)[A] and may require neuroimaging to rule out neoplasms (6)[A].
COMPLICATIONS
- Corneal abrasion or ulceration
- Steroid-induced psychological disturbances; avascular necrosis of the hips, knees, and/or shoulders
- Steroid use can unmask subclinical infection (e.g., TB).
REFERENCES
11 Katz A, Sergienko R, Dior U, et al. Bell's palsy during pregnancy: is it associated with adverse perinatal outcome? Laryngoscope. 2011;121(7):1395-1398.22 Peng KP, Chen YT, Fuh JL, et al. Increased risk of Bell palsy in patients with migraine: a nationwide cohort study. Neurology. 2015;84(2):116-124.33 Thaera GM, Wellik KE, Barrs DM, et al. Are corticosteroid and antiviral treatments effective for bell palsy? A critically appraised topic. Neurologist. 2010;16(12):138-140.44 Worster A, Keim SM, Sahsi R, et al. Do either corticosteroids or antiviral agents reduce the risk of long-term facial paresis in patients with new-onset Bell's palsy? J Emerg Med. 2010;38(4):518-523.55 Madhok V, Falk G, Fahey T, et al. Prescribe prednisolone alone for Bell's palsy diagnosed within 72 hours of symptom onset. BMJ. 2009;338:b255.66 de Almeida JR, Guyatt GH, Sud S, et al. Management of Bell palsy: clinical practice guideline. CMAJ. 2014;186(12):917-922.77 Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2011;(12):CD006283.88 Ferreira M, Marques EE, Duarte JA, et al. Physical therapy with drug treatment in Bell palsy: a focused review. Am J Phys Med Rehabil. 2015;94(4):331-340.99 Pourmomeny AA, Asadi S. Management of synkinesis and asymmetry in facial nerve palsy: a review article. Iran J Otorhinolaryngol. 2014;26(77):251-256.1010 Alakram P, Puckree T. Effects of electrical stimulation on House-Brackmann scores in early Bell's palsy. Physiother Theory Pract. 2010;26(3):160-166.1111 Axelsson S, Berg T, Jonsson L, et al. Prednisolone in Bell's palsy related to treatment start and age. Otol Neurotol. 2011;32(1):141-146.1212 Marsk E, Bylund N, Jonsson L, et al. Prediction of nonrecovery in Bell's palsy using Sunnybrook grading. Laryngoscope. 2012;122(4):901-906.
SEE ALSO
Amyloidosis; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Herpes Simplex; Herpes Zoster (Shingles); Lyme Disease; Sarcoidosis; Sj ¶gren Syndrome
CODES
ICD10
G51.0 Bell's palsy
ICD9
351.0 Bell's palsy
SNOMED
- 193093009 Bell's palsy (disorder)
- 12239621000119103 Bells palsy of left side of face (disorder)
- 12239661000119108 Bells palsy of right side of face (disorder)
CLINICAL PEARLS
- Initiate steroids immediately following the onset of symptoms.
- Look closely at the voluntary movement on the upper part of the face on the affected side; in Bell palsy, all of the muscles are involved (weak or paralyzed); whereas in a stroke, the upper muscles are spared (because of bilateral innervation).
- Protect the affected eye with lubrication and taping.
- In areas with endemic Lyme disease, Bell palsy should be considered to be Lyme disease until proven otherwise.