Bell's Palsy¶

DIAGNOSIS: Bell's Palsy (Idiopathic Facial Nerve Palsy) ICD-10: G51.0 (Bell's palsy) SCOPE: Acute unilateral peripheral facial nerve palsy of presumed idiopathic etiology. Covers initial evaluation, treatment, and follow-up. Excludes Ramsay Hunt syndrome (herpes zoster oticus), central facial palsy, bilateral facial palsy, and secondary causes.

STATUS: Draft - Pending Review

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

CRITICAL: Time-Sensitive Treatment - Corticosteroids must be started within 72 hours of symptom onset for maximum benefit - Treatment initiated after 72 hours has significantly reduced efficacy - House-Brackmann Grade V-VI (severe/complete paralysis) may benefit from adjunctive antiviral therapy

RED FLAGS (Consider Alternative Diagnosis)

Red Flag	Concern	Action
Bilateral facial weakness	Lyme disease, GBS, sarcoidosis, leukemia	Comprehensive workup; do NOT assume Bell's palsy
Slow progression (>3 weeks)	Tumor, malignancy	MRI with contrast urgently
Recurrent facial palsy	Tumor, Melkersson-Rosenthal syndrome	MRI; specialist referral
No improvement at 4 months	Incomplete recovery, synkinesis risk	EMG/NCS; consider referral
Facial twitching preceding weakness	Facial nerve tumor	MRI IAC/temporal bone
Other cranial nerve involvement	Brainstem lesion, skull base pathology	Urgent MRI/CT
Hyperacusis with vesicles in ear canal	Ramsay Hunt syndrome (VZV)	Treat as Ramsay Hunt (higher antiviral doses)
Systemic symptoms (rash, arthritis, tick exposure)	Lyme disease	Lyme serology

SECTION A: ACTION ITEMS¶

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Glucose or HbA1c	Diabetes is risk factor and affects prognosis	Normal glucose; HbA1c <7%	ROUTINE	ROUTINE	ROUTINE	-

1B. Extended Workup (Second-line)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Lyme serology (ELISA + Western blot)	Endemic areas or tick exposure; bilateral palsy	Negative	ROUTINE	ROUTINE	ROUTINE	-
CBC with differential	Concern for leukemia or infection	Normal	ROUTINE	ROUTINE	ROUTINE	-
ESR, CRP	Inflammatory etiology suspected	Normal	-	ROUTINE	ROUTINE	-
HIV testing	Risk factors present; atypical or recurrent	Negative	-	ROUTINE	ROUTINE	-
RPR/VDRL	Syphilis can cause cranial neuropathies	Nonreactive	-	ROUTINE	ROUTINE	-

1C. Rare/Specialized (Refractory or Atypical)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
ACE level, chest imaging	Sarcoidosis suspected (bilateral, recurrent, uveitis)	Normal ACE; clear CXR	-	EXT	EXT	-
ANA, anti-Ro/La	Autoimmune etiology suspected	Negative	-	EXT	EXT	-
CSF analysis	Lyme neuroborreliosis, GBS, or carcinomatous meningitis suspected	Normal; negative Lyme	-	EXT	EXT	-

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
None routinely required	N/A	Clinical diagnosis sufficient for typical Bell's palsy	N/A	-	-	-	-

2B. Extended¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain with contrast	Atypical features, no improvement by 4 months, recurrent	Enhancement of facial nerve (may be normal in Bell's); exclude tumor	MRI-incompatible devices; gadolinium allergy	-	EXT	ROUTINE	-
MRI IAC/Temporal bone	Suspected tumor, Ramsay Hunt, or recurrent palsy	Exclude schwannoma, hemangioma, cholesteatoma	MRI-incompatible devices	-	EXT	EXT	-
CT Head non-contrast	Concern for stroke (upper and lower face affected)	Exclude acute CVA	Pregnancy (relative)	STAT	STAT	-	-

2C. Rare/Specialized¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Electroneuronography (ENoG)	Days 3-14 for severe palsy	>90% degeneration may indicate need for decompression	Too early (<3 days) or late (>3 weeks)	-	EXT	EXT	-
EMG facial nerve	After 2-3 weeks if complete palsy; at 4 months if no recovery	Evidence of reinnervation; fibrillations indicate denervation	None	-	EXT	EXT	-
Needle EMG (blink reflex)	Assessing recovery potential	Present R1 response indicates favorable prognosis	None	-	EXT	EXT	-

3. TREATMENT¶

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Prednisone	PO	First-line treatment; must start within 72 hours of onset	60 mg daily x 5 days; 60 mg daily x 5 days then taper :: PO :: :: 60-80 mg daily for 5 days, then taper over 5 days (or 60 mg x 5d then 10 mg daily decrease); total 10 days	Uncontrolled diabetes (relative); active systemic infection; psychosis	Glucose in diabetics; mood changes	URGENT	URGENT	URGENT	-
Prednisolone	PO	Alternative to prednisone; may have better bioavailability	50 mg daily x 10 days; 25 mg BID x 10 days :: PO :: :: 50 mg daily (or 25 mg BID) for 10 days	Same as prednisone	Glucose in diabetics	URGENT	URGENT	URGENT	-
Valacyclovir	PO	Adjunct for severe (HB V-VI) or complete facial paralysis	1000 mg TID x 7 days :: PO :: :: 1000 mg PO TID for 7 days; start within 72 hours; always combine with corticosteroid	Renal impairment (dose adjust); hypersensitivity	Renal function in CKD	URGENT	URGENT	ROUTINE	-
Acyclovir	PO	Alternative antiviral if valacyclovir unavailable	400 mg 5x/day x 10 days :: PO :: :: 400 mg PO 5 times daily for 10 days; always combine with corticosteroid	Renal impairment (dose adjust); hypersensitivity	Renal function in CKD	URGENT	URGENT	ROUTINE	-

3B. Symptomatic Treatments¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Artificial tears (carboxymethylcellulose)	TOP	Eye protection during waking hours; prevents exposure keratopathy	1-2 drops q1-2h while awake :: TOP :: :: 1-2 drops to affected eye every 1-2 hours while awake; increase frequency as needed	None	Corneal status	URGENT	ROUTINE	ROUTINE	-
Lubricating eye ointment (lacri-lube)	TOP	Nighttime eye protection; prevents corneal drying during sleep	Apply qHS :: TOP :: :: Apply 1/4 inch ribbon to affected eye at bedtime	None	Corneal status	URGENT	ROUTINE	ROUTINE	-
Eye patch/Moisture chamber	TOP	Corneal protection especially at night or outdoors	Use during sleep and windy conditions :: TOP :: :: Tape eye closed at night; use moisture chamber glasses during day if severe lagophthalmos	None	Ensure complete closure; no corneal contact	URGENT	ROUTINE	ROUTINE	-
Surgical tape (for eye closure)	TOP	Ensure complete eyelid closure during sleep	Apply at bedtime :: TOP :: :: Use hypoallergenic tape to gently tape eyelid closed at night; vertical taping preferred	Skin sensitivity; ensure no tape touches cornea	Skin irritation; corneal status	URGENT	ROUTINE	ROUTINE	-
Acetaminophen	PO	Postauricular pain associated with Bell's palsy	650 mg q6h PRN; 1000 mg q6h PRN :: PO :: :: 650-1000 mg PO q6h PRN pain; max 3000 mg/day	Hepatic impairment; avoid with alcohol	Hepatic function with prolonged use	ROUTINE	ROUTINE	ROUTINE	-
Ibuprofen	PO	Postauricular pain; mild anti-inflammatory effect	400 mg q6h PRN; 600 mg q6h PRN :: PO :: :: 400-600 mg PO q6h PRN pain; max 2400 mg/day	Renal impairment; GI bleed; aspirin allergy	GI symptoms; renal function	ROUTINE	ROUTINE	ROUTINE	-

3C. Second-line/Refractory¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Botulinum toxin A	IM	Synkinesis or hemifacial spasm following recovery	2.5-5 units per site :: IM :: :: Inject 2.5-5 units per site in affected muscles; dose varies by target muscle; repeat q3-4 months	Infection at site; myasthenia gravis; aminoglycosides	Weakness, ptosis, asymmetry	-	-	EXT	-
Physical therapy (facial)	N/A	Facilitate recovery; prevent contracture; treat synkinesis	Per PT protocol :: N/A :: :: Facial exercises, massage, mirror biofeedback; start after acute phase	None	Compliance; progress	-	ROUTINE	ROUTINE	-
Facial nerve decompression	Surgical	ENoG shows >90% degeneration within 14 days; controversial	Surgical referral :: N/A :: :: Consider if >90% degeneration on ENoG within 2 weeks of onset; rarely performed	Surgical contraindications	Post-operative course; hearing	-	EXT	EXT	-
Gold weight implant	Surgical	Chronic lagophthalmos with corneal exposure risk	Surgical referral :: N/A :: :: For persistent incomplete eye closure after 6-12 months	Surgical contraindications	Corneal protection; cosmesis	-	-	EXT	-
Tarsorrhaphy	Surgical	Severe corneal exposure not controlled medically	Surgical referral :: N/A :: :: Temporary or permanent suturing of eyelids for corneal protection	Surgical contraindications	Corneal status	-	EXT	EXT	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Ophthalmology referral urgently if corneal involvement, severe lagophthalmos, or eye pain concerning for exposure keratopathy	URGENT	URGENT	URGENT	-
Neurology referral if atypical features, no improvement by 3-4 weeks, or concern for central etiology	-	ROUTINE	ROUTINE	-
ENT/Otolaryngology referral if Ramsay Hunt suspected, recurrent palsy, or consideration of surgical decompression	-	ROUTINE	ROUTINE	-
Physical therapy referral for facial rehabilitation, particularly if incomplete recovery or synkinesis	-	-	ROUTINE	-
Plastic surgery/Oculoplastic referral for chronic lagophthalmos requiring surgical intervention (gold weight, tarsorrhaphy)	-	-	EXT	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Return immediately for eye pain, redness, or vision changes which may indicate corneal injury from exposure	STAT	ROUTINE	ROUTINE
Return if facial weakness worsens after initial improvement or new symptoms develop (numbness, hearing loss, other weakness)	URGENT	ROUTINE	ROUTINE
Protect affected eye from wind, dust, and debris with glasses or moisture chamber during recovery	ROUTINE	ROUTINE	ROUTINE
Use artificial tears frequently during the day and lubricating ointment at night; tape eye closed if unable to fully close	URGENT	ROUTINE	ROUTINE
Most patients (70-85%) recover completely; recovery typically begins within 3 weeks and completes within 3-4 months	-	ROUTINE	ROUTINE
Do not discontinue steroids abruptly as this may cause adrenal insufficiency; complete the full taper as prescribed	URGENT	ROUTINE	ROUTINE
Facial exercises may help recovery; gently massage face and practice facial movements in mirror several times daily	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Adequate sleep and stress management as viral reactivation may be triggered by stress and immunosuppression	-	ROUTINE	ROUTINE
Avoid extreme cold and wind exposure to face during recovery period to prevent irritation	-	ROUTINE	ROUTINE
Diabetic patients should maintain strict glycemic control as hyperglycemia worsens prognosis and slows recovery	-	ROUTINE	ROUTINE
Avoid driving if unable to fully close eye or if vision is significantly impaired	ROUTINE	ROUTINE	ROUTINE

SECTION B: REFERENCE¶

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Stroke (central facial palsy)	Forehead sparing; upper face moves normally; other neurological deficits	CT/MRI brain; complete neurological exam
Ramsay Hunt syndrome (VZV)	Vesicles in ear canal or on pinna; severe otalgia; worse prognosis	Clinical exam for vesicles; VZV PCR if needed
Lyme disease (facial palsy)	Endemic area; tick exposure; bilateral (25%); erythema migrans; arthralgias	Lyme ELISA + Western blot
Otitis media with facial palsy	Ear pain, otorrhea, conductive hearing loss, fever	Otoscopic exam; CT temporal bone
Parotid tumor/malignancy	Slow onset; parotid mass; progressive; no recovery	MRI parotid; FNA or biopsy
Acoustic neuroma (schwannoma)	Gradual onset; hearing loss; tinnitus; facial numbness	MRI IAC with contrast
Cholesteatoma	Chronic ear disease; hearing loss; otorrhea	Otoscopy; CT temporal bone
Guillain-Barré syndrome	Bilateral facial weakness; limb weakness; areflexia	LP (albuminocytologic dissociation); EMG/NCS
Sarcoidosis (Heerfordt syndrome)	Bilateral; uveitis; parotid swelling; fever	ACE level; chest imaging; biopsy
Melkersson-Rosenthal syndrome	Recurrent palsy; facial edema; fissured tongue	Clinical triad; biopsy if needed

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
House-Brackmann grade	Each visit	Progressive improvement; Grade I-II by 4 months	EMG if no improvement; consider referral	ROUTINE	ROUTINE	ROUTINE	-
Corneal examination (fluorescein)	Initial and PRN symptoms	No corneal staining or ulceration	Urgent ophthalmology; increase eye protection	URGENT	ROUTINE	ROUTINE	-
Eye closure (lagophthalmos)	Each visit	Complete closure; Bell phenomenon present	Intensify lubrication; consider tarsorrhaphy referral	ROUTINE	ROUTINE	ROUTINE	-
Glucose (if on steroids)	Daily if diabetic x 10 days	<180 mg/dL; HbA1c stable	Adjust diabetes medications; endocrine consult	-	ROUTINE	ROUTINE	-
Synkinesis development	Starting at 4-8 weeks	None or minimal	Physical therapy; consider botulinum toxin	-	-	ROUTINE	-
Recovery timeline	Weeks 3, 6, 12, and 6 months	Initial recovery by 3 weeks; near-complete by 4-6 months	EMG at 4 months; consider secondary causes	-	-	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Typical presentation; able to protect eye; steroids initiated within 72 hours; follow-up arranged
Admit to floor	Rare; only if unable to protect eye and no caregiver; severe comorbidities affecting steroid use; concern for secondary cause requiring inpatient workup
Admit to ICU	Not applicable for Bell's palsy
Outpatient follow-up	2-3 weeks initial follow-up to assess recovery; earlier if corneal symptoms; neurology referral if no improvement by 4-6 weeks

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Corticosteroids improve recovery rates	Class I, Level A	Sullivan et al. NEJM 2007 (Scottish Bell's Palsy Study)
Antiviral monotherapy not effective; corticosteroids superior	Class I, Level A	Engstrom et al. NEJM 2008
Combination corticosteroid + antiviral may benefit severe cases	Class I, Level B	de Almeida et al. JAMA 2009 (meta-analysis)
Early treatment (within 72 hours) improves outcomes	Class II, Level B	Madhok et al. Cochrane 2016
AAN Practice Parameter: Steroids highly effective	Class I, Level A	Gronseth & Paduga. Neurology 2012 (AAN Guideline)
Eye protection prevents corneal complications	Class III, Level C	Expert consensus; standard of care
House-Brackmann grading system for assessment	Clinical standard	House & Brackmann. Otolaryngol Head Neck Surg 1985
ENoG >90% degeneration predicts poor outcome	Class II, Level B	Fisch. Otolaryngol Head Neck Surg 1984
Physical therapy may improve recovery	Class III, Level C	Teixeira et al. Cochrane 2011
Botulinum toxin effective for post-paralytic synkinesis	Class II, Level B	Mehdizadeh et al. Plast Reconstr Surg 2008

CHANGE LOG¶

v1.0 (January 27, 2026) - Initial template creation - Comprehensive coverage of diagnosis, treatment, and follow-up - Emphasis on time-sensitive corticosteroid initiation - Eye protection protocols detailed - House-Brackmann grading included in appendix - Red flags for atypical presentations - Real PubMed citations verified

APPENDIX A: House-Brackmann Facial Nerve Grading Scale¶

Grade	Description	Characteristics
I	Normal	Normal facial function in all areas
II	Mild dysfunction	Slight weakness noticeable on close inspection; may have very slight synkinesis; complete eye closure with minimal effort
III	Moderate dysfunction	Obvious but not disfiguring difference; noticeable but not severe synkinesis; complete eye closure with effort
IV	Moderately severe dysfunction	Obvious weakness and/or disfiguring asymmetry; incomplete eye closure
V	Severe dysfunction	Only barely perceptible motion; incomplete eye closure
VI	Total paralysis	No movement

Clinical Significance: - Grade I-II: Excellent prognosis; minimal treatment needed beyond eye protection - Grade III-IV: Good prognosis with treatment; monitor for synkinesis - Grade V-VI: Consider adjunctive antiviral therapy; ENoG may guide prognosis; higher risk of incomplete recovery

APPENDIX B: Recovery Prognosis and Timeline¶

Expected Recovery Timeline: - Days 1-7: Symptoms may worsen initially even with treatment - Weeks 1-3: First signs of recovery typically appear - Weeks 3-8: Significant improvement in most patients - Months 2-4: Near-complete recovery in majority - Months 4-12: Late recovery possible; synkinesis may develop

Prognostic Factors:

Factor	Better Prognosis	Worse Prognosis
Severity at onset	Incomplete paralysis (HB II-III)	Complete paralysis (HB V-VI)
Treatment timing	Steroids within 72 hours	Delayed treatment
Age	Younger patients	Older patients (>60)
Comorbidities	None	Diabetes, hypertension
Recovery onset	Within 3 weeks	After 4 months
ENoG findings	<90% degeneration	>90% degeneration

Overall Outcomes: - 70-85% of patients recover completely (HB I-II) - 10-15% have mild residual weakness (HB III) - 5-10% have moderate to severe residual weakness (HB IV-VI) - ~16% develop synkinesis (involuntary facial movements) - Recurrence rate: 7-12% (same or opposite side)

APPENDIX C: Eye Protection Protocol¶

Importance: The inability to fully close the eye leads to corneal exposure, drying, and potential ulceration. Corneal injury is the most serious complication of Bell's palsy.

Daytime Protocol: 1. Artificial tears (preservative-free preferred): Every 1-2 hours while awake 2. Wear wrap-around glasses or moisture chamber when outdoors 3. Avoid fans, air conditioning directly on face 4. Blink consciously and frequently

Nighttime Protocol: 1. Apply lubricating ointment (e.g., Lacri-Lube) before bed 2. Tape eyelid closed using hypoallergenic tape (vertical strip from eyebrow to cheek) 3. Consider moisture chamber patch 4. Elevate head of bed slightly

Warning Signs Requiring Urgent Ophthalmology: - Eye pain or foreign body sensation - Eye redness - Discharge from eye - Vision changes or blurring - Photophobia

When to Consider Surgical Eye Protection: - Persistent lagophthalmos beyond 6-12 months - Corneal breakdown despite medical management - Options: Gold weight implant, tarsal strip, tarsorrhaphy