Clinical Practice Guideline: Bell's Palsy Executive Summary

The Clinical Practice Guideline: Bell's Palsy is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. The guideline's target audience includes specialists, primary care clinicians, and allied health professionals, as represented by this multidisciplinary guideline development group. Recommendations were developed to encourage accurate and efficient diagnosis and treatment and, when applicable, facilitate patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. Recommendations in a guideline can be implemented only if they are clear and identifiable. This goal is best achieved by structuring the guideline around a series of key action statements, which are supported by amplifying text and action statement profiles. For ease of reference, only the statements and profiles are included in this brief summary. Please refer to the complete guideline for important information in the amplifying text that further explains the supporting evidence and details of implementation for each key action statement.¹

Background

Bell's palsy is a relatively uncommon condition but one that affects people across the age and gender spectrum, with incidence ranging from 11.5 to 53.3 per 100,000 person years in different populations.^2-6 Notably, Bell's palsy is seen in the pediatric population, with one study citing an incidence of approximately 6.1 in 100,000 in children 1 to 15 years of age.⁷ In one integrated health system, the incidence of Bell's palsy in children 18 years or younger was 18.8 per 100,000 person-years in a 5-year study.⁸ In that study, the incidence rate increased by age and was higher in females than males across all age strata. Although Bell's palsy is seen in patients across a large age spectrum, the incidence was noted to be highest in the 15- to 45-year-old age group.⁹

The guideline development group (GDG) recognizes that Bell's palsy is a diagnosis of exclusion requiring the careful elimination of other causes of facial paresis or paralysis. Although the literature is silent on the precise definition of what constitutes acute onset in facial paralysis, the GDG accepted the definition of “acute” or “rapid onset” to mean that the occurrence of paresis/paralysis typically progresses to its maximum severity within 72 hours of onset of the paresis/paralysis (Table 1). This guideline does not focus on facial paresis/paralysis due to neoplasms, trauma, congenital or syndromic problems, specific infectious agents, or postsurgical facial paresis or paralysis, nor does it address recurrent facial paresis/paralysis. For the purposes of this guideline, Bell's palsy is defined as “acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours and without an identifiable cause” (Table 1).

While a viral etiology is suspected, the exact mechanism of Bell's palsy is currently unknown.¹⁰ Facial paresis or paralysis is thought to result from facial nerve inflammation and edema. As the facial nerve travels in a narrow canal within the temporal bone, swelling may lead to nerve compression and result in temporary or permanent nerve damage. The facial nerve carries nerve impulses to muscles of the face and also to the lacrimal glands, salivary glands, stapedius muscle, taste fibers from the anterior tongue, and general sensory fibers from the tympanic membrane and posterior ear canal. Accordingly, patients with Bell's palsy may experience dryness of the eye or mouth, taste disturbance or loss, hyperacusis, and sagging of the eyelid or corner of the mouth.^{11, 12} Ipsilateral pain around the ear or face is not an infrequent presenting symptom.^{10, 13}

Most patients with Bell's palsy show some recovery without intervention within 2 to 3 weeks after onset of symptoms and completely recover within 3 to 4 months.⁹ Moreover, even without treatment, facial function is completely restored in approximately 70% of Bell's palsy patients with complete paralysis within 6 months and as high as 94% of patients with incomplete paralysis; accordingly, as many as 30% of patients do not recover completely.¹⁴ Given the dramatic effect of facial paralysis on patient appearance, quality of life, and psychological well-being, treatment is often initiated in an attempt to decrease the likelihood of incomplete recovery. Corticosteroids and antiviral medications are the most commonly used medical therapies. New trials have explored the benefit of these medications. The benefit of surgical decompression of the facial nerve remains relatively controversial.¹⁵

The psychological burden of facial paralysis can be tremendous. Facial expression is fundamental to one's sense of well-being and ability to integrate into a social network.¹⁸ With diminished facial movement and marked facial asymmetry, patients with facial paralysis can have impaired interpersonal relationships and experience profound social distress, depression, and social alienation.¹⁹ Recent data show that patients with facial paralysis are perceived by casual observers as emoting negatively when compared with individuals without paralyzed faces and that they are considered significantly less attractive.²⁰ There are links between diminished attractiveness and depression, and these data may suggest that patients with paralyzed faces are at risk for depression, which can lead to decreased productivity and increased health care expenses.

Purpose

The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for Bell's palsy patients, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy.

This guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the GDG and is not intended to be a comprehensive guide for diagnosing and managing Bell's palsy. A comprehensive list of the topics and issues considered by the GDG is available in Table 2. The recommendations outlined in this guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients. The guideline is not intended to replace clinical judgment for individualized patient care. Our goal is to create a multidisciplinary guideline with a specific set of focused recommendations based on an established and transparent process that considers levels of evidence, harm-benefit balance, and expert consensus to resolve gaps in evidence. These specific recommendations are designed to improve quality of care and may be used to develop performance measures.

There are myriad treatment options for Bell's palsy; some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, there are numerous diagnostic tests available that are used in the evaluation of Bell's palsy patients. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while Bell's palsy patients enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have an unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

Methods

This guideline was developed using an explicit and transparent a priori protocol for creating actionable statements based on supporting evidence and the associated balance of benefit and harm.²¹ Members of the panel included otolaryngology–head and neck surgery, neurology, facial plastic and reconstructive surgery, neurotology, emergency medicine, primary care, otology, nursing, physician assistants, and consumer advocacy. For additional details on methodology, please refer to the complete text of the guideline.¹ The 11 guideline recommendations are summarized in Table 3, with the corresponding action statements and profiles reproduced below. Supporting text and complete citations can be found in the guideline proper.¹

Key Action Statements

STATEMENT 1. PATIENT HISTORY AND PHYSICAL EXAMINATION: Clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute onset unilateral facial paresis or paralysis. Strong recommendation based on observational studies of alternative causes of facial paralysis and reasoning from first principles, with a preponderance of benefit over harm.

Disclaimer

This clinical practice guideline is provided for informational and educational purposes only. It is not intended as a sole source of guidance in managing Bell's palsy. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to diagnosing and managing this program of care. As medical knowledge expands and technology advances, clinical indicators and guidelines are promoted as conditional and provisional proposals of what is recommended under specific conditions, but they are not absolute. Guidelines are not mandates and do not and should not purport to be a legal standard of care. The responsible physician, in light of all the circumstances presented by the individual patient, must determine the appropriate treatment. Adherence to these guidelines will not ensure successful patient outcomes in every situation. The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) emphasizes that these clinical guidelines should not be deemed to include all proper treatment decisions or methods of care or to exclude other treatment decisions or methods of care reasonably directed to obtaining the same results.

© 2013 American Academy of Otolaryngology—Head and Neck Surgery Foundation. All rights reserved.

Author Contributions

Reginald Baugh, writer, chair; Gregory Basura, writer, assistant chair; Lisa Ishii, writer, assistant chair; Seth R. Schwartz, writer, consultant; Caitlin Murray Drumheller, writer, AAO-HNSF staff liaison; Rebecca Burkholder, writer, panel member; Nathan A. Deckard, writer, panel member; Cindy Dawson, writer, panel member; Colin Driscoll, writer, panel member; M. Boyd Gillespie, writer, panel member; Richard K. Gurgel, writer, panel member; John Halperin, writer, panel member; Ayesha N. Khalid, writer, panel member; Kaparaboyna Ashok Kumar, writer, panel member; Alan Micco, writer, panel member; Debra Munsell, writer, panel member; Steven Rosenbaum, writer, panel member; William Vaughan, writer, panel member.

Disclosures

Competing interests: Seth R. Schwartz, Cochlear Corporation research grant; Caitlin Murray Drumheller, salaried employee of AAO-HNSF; Colin Driscoll, surgeon advisor and board member for Cochlear Corporation, Advanced Bionics, MED-EL Corporation; M. Boyd Gillespie, grant support/consultant–sleep apnea for Gyrus-Olympus, Medtronic, Inspire Medical; John Halperin, stockholder in Abbott, Bristol Myers, Johnson & Johnson, Merck; expert witness in defending physicians in medical malpractice cases; editorial board, The Neurologist; Ayesha N. Khalid, Acclarent fellowship research training grant (2008-2009); Kaparaboyna Ashok Kumar, consultant, Southeast Fetal Alcohol Spectrum Disorders Training Center, Meharry Medical College, and speaker (teach hospitalist procedures), National Procedures Institute; Alan Micco, Speakers Bureau, Alcon Labs; Steven Rosenbaum, stockholder in Pfizer, Johnson & Johnson, GlaxoSmithKline, Sanofi, Celgene Corporation.

Sponsorships: American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Funding source: American Academy of Otolaryngology—Head and Neck Surgery Foundation.