Bell's Palsy¶

VERSION: 1.0 CREATED: January 29, 2026 REVISED: January 29, 2026 STATUS: Approved

DIAGNOSIS: Bell's Palsy / Idiopathic Facial Paralysis

ICD-10: G51.0 (Bell's palsy), G51.8 (Other disorders of facial nerve), G51.9 (Disorder of facial nerve, unspecified), B02.21 (Postherpetic geniculate ganglionitis - Ramsay Hunt)

CPT CODES: 85025 (CBC), 80053 (CMP), 82947 (Glucose), 86618 (Lyme serology), 85652 (ESR), 87389 (HIV), 86592 (RPR/VDRL), 86235 (ANA), 82164 (ACE level), 62270 (CSF analysis (LP)), 70553 (MRI brain with IAC protocol), 70552 (MRI with contrast), 70480 (CT temporal bone), 71046 (Chest X-ray), 95885 (Electrodiagnostic studies (ENoG, EMG)), 96374 (Methylprednisolone IV), 96365 (Acyclovir IV (severe Ramsay Hunt))

SYNONYMS: Bell's palsy, Bell palsy, idiopathic facial paralysis, facial palsy, facial nerve palsy, acute peripheral facial palsy, seventh nerve palsy, CN VII palsy, facial weakness, facial droop, facial paralysis

SCOPE: Diagnosis and management of Bell's palsy (idiopathic facial nerve palsy) in adults. Covers workup to exclude secondary causes, medical treatment, and eye protection. Includes Ramsay Hunt syndrome (herpes zoster oticus) which requires different treatment. Excludes central facial palsy (stroke), facial nerve tumors, traumatic facial nerve injury, and bilateral facial palsy workup.

DEFINITIONS: - Bell's Palsy: Acute idiopathic unilateral peripheral facial nerve (CN VII) weakness - Peripheral Facial Palsy: Weakness affecting upper AND lower face (forehead involvement) - Central Facial Palsy: Weakness affecting lower face only with forehead sparing (upper motor neuron lesion) - House-Brackmann Scale: Grading system for facial nerve function (I-VI) - Ramsay Hunt Syndrome: Facial palsy with herpes zoster oticus (vesicles in ear canal/pinna)

HOUSE-BRACKMANN GRADING SCALE:

Grade	Description	Characteristics
I	Normal	Normal facial function
II	Mild dysfunction	Slight weakness on close inspection; complete eye closure with effort
III	Moderate dysfunction	Obvious but not disfiguring weakness; may not completely close eye; forehead movement present
IV	Moderately severe	Obvious weakness and disfiguring asymmetry; cannot completely close eye; no forehead movement
V	Severe dysfunction	Barely perceptible motion; incomplete eye closure; slight movement at corner of mouth
VI	Total paralysis	No movement; loss of tone

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

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (CPT 85025)	URGENT	ROUTINE	ROUTINE	-	Infection, leukemia (CN involvement)	Normal
CMP (CPT 80053)	URGENT	ROUTINE	ROUTINE	-	Diabetes (risk factor), electrolytes	Normal; glucose <126 fasting
Glucose (CPT 82947) / HbA1c (CPT 83036)	URGENT	ROUTINE	ROUTINE	-	Diabetes is major risk factor; affects prognosis	Normal

1B. Extended Workup (Second-line - Selected Patients)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Lyme serology (CPT 86618) (IgM/IgG)	-	ROUTINE	ROUTINE	-	Endemic areas; Lyme disease can cause facial palsy	Negative
ESR (CPT 85652) / CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	Inflammatory conditions, vasculitis	Normal
HIV (CPT 87389)	-	ROUTINE	ROUTINE	-	HIV-associated facial palsy	Negative
RPR/VDRL (CPT 86592)	-	ROUTINE	ROUTINE	-	Syphilis in differential	Negative
ANA (CPT 86235)	-	EXT	EXT	-	Autoimmune etiology (SLE, Sjogren's)	Negative
SSA (Ro) / SSB (La)	-	EXT	EXT	-	Sjogren's syndrome	Negative
VZV serology (IgM)	-	ROUTINE	ROUTINE	-	Ramsay Hunt syndrome (if vesicles or suspicion)	Document status
ACE level (CPT 82164)	-	EXT	EXT	-	Sarcoidosis if bilateral or recurrent	Normal

1C. Rare/Specialized¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CSF analysis (LP) (CPT 62270)	-	URGENT	-	-	Atypical presentation, suspected Lyme neuroborreliosis, GBS, meningitis	See LP section
Serum glucose tolerance test	-	-	ROUTINE	-	If HbA1c borderline; diabetes evaluation	Normal

LUMBAR PUNCTURE¶

Indication: Atypical features (bilateral, progressive, recurrent), suspected Lyme disease, meningitis, or GBS

Study	ED	HOSP	OPD	ICU	Rationale	Target Finding
Opening pressure	URGENT	URGENT	-	-	Baseline; elevated in some conditions	10-20 cm H2O
Cell count (tubes 1 and 4)	URGENT	URGENT	-	-	Infection, inflammation	WBC <5
Protein	URGENT	URGENT	-	-	Elevated in GBS, Lyme	15-45 mg/dL
Glucose	URGENT	URGENT	-	-	Infection	>60% serum
Lyme antibody (CSF)	-	URGENT	-	-	Lyme neuroborreliosis	Negative
VDRL (CSF)	-	URGENT	-	-	Neurosyphilis	Negative
Gram stain and culture	-	URGENT	-	-	Bacterial meningitis	No organisms
CSF meningitis panel	-	URGENT	-	-	Viral/bacterial pathogens	Negative

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Physical examination	STAT	STAT	ROUTINE	-	At presentation	Peripheral pattern (forehead involved); no other CN deficits	None
Otoscopic examination	STAT	STAT	ROUTINE	-	At presentation	Vesicles (Ramsay Hunt); middle ear pathology	None
Eye examination	STAT	STAT	ROUTINE	-	At presentation	Corneal exposure, lagophthalmos	None

2B. Extended (Atypical or Non-recovering Cases)¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with IAC protocol (CPT 70553)	-	ROUTINE	ROUTINE	-	If atypical, progressive, no recovery at 4-6 weeks	Facial nerve enhancement (may be normal in Bell's); exclude mass, stroke	Pacemaker, metal
MRI with contrast (CPT 70552)	-	ROUTINE	ROUTINE	-	If tumor suspected	Rule out schwannoma, parotid tumor	Contrast allergy
CT temporal bone (CPT 70480)	-	ROUTINE	ROUTINE	-	If trauma or mastoid pathology suspected	Fracture, cholesteatoma	None
Chest X-ray (CPT 71046)	-	ROUTINE	ROUTINE	-	If sarcoidosis suspected	Hilar adenopathy	None
Electrodiagnostic studies (ENoG, EMG) (CPT 95885)	-	-	ROUTINE	-	Severe palsy (HB IV-VI) at 2-3 weeks; prognosis	>90% degeneration = poor prognosis	None

3. TREATMENT¶

3A. Corticosteroids (All Patients)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Prednisone	PO	-	60-80 mg :: PO :: daily :: 60-80 mg PO daily × 7 days (can taper over days 8-10 or stop); START WITHIN 72 HOURS of onset	Active infection (relative), uncontrolled DM (relative)	Glucose (especially diabetics), GI prophylaxis	STAT	STAT	ROUTINE	-
Prednisolone	PO	-	60-80 mg :: PO :: daily :: 60-80 mg PO daily × 7 days (equivalent alternative)	Same	Same	STAT	STAT	ROUTINE	-
Methylprednisolone IV (CPT 96374)	IV	-	1000 mg :: IV :: daily :: 1000 mg IV daily × 3-5 days (if unable to take PO or severe/Ramsay Hunt)	Same	Same	STAT	STAT	-	-
Dexamethasone (CPT 96374)	IV	-	10 mg :: IV :: daily :: 10 mg IV/PO daily × 7-10 days (alternative)	Same	Same	STAT	STAT	-	-

3B. Antiviral Therapy¶

Note: Antivirals alone have NOT been shown to improve outcomes in Bell's palsy. Use in combination with steroids for moderate-severe cases and always for Ramsay Hunt syndrome.

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Valacyclovir (moderate-severe Bell's)	PO	-	1000 mg :: PO :: TID :: 1000 mg PO TID × 7 days; ALWAYS with steroids	Renal impairment (reduce dose)	Renal function	STAT	STAT	ROUTINE	-
Acyclovir (alternative)	PO	-	400 mg :: PO :: daily :: 400 mg PO 5× daily × 7-10 days; or 800 mg PO TID × 7 days	Renal impairment	Renal function	STAT	STAT	ROUTINE	-
Valacyclovir (Ramsay Hunt)	PO	-	1000 mg :: PO :: TID :: 1000 mg PO TID × 7-10 days; MANDATORY with steroids	Renal impairment	Renal function	STAT	STAT	ROUTINE	-
Acyclovir IV (severe Ramsay Hunt) (CPT 96365)	IV	-	10 mg/kg :: IV :: q8h :: 10 mg/kg IV q8h × 7-10 days	Renal impairment	Renal function, hydration	-	STAT	-	-

3C. Eye Protection (CRITICAL - All Patients)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Artificial tears (preservative-free)	-	-	1-2 drops :: - :: q1-2h :: 1-2 drops affected eye q1-2h while awake	None	Corneal status	STAT	STAT	ROUTINE	-
Lubricating eye ointment (Lacri-Lube)	-	-	N/A :: - :: TID :: Thin strip in affected eye at bedtime (and up to TID)	None	Corneal status	STAT	STAT	ROUTINE	-
Eye patch or moisture chamber	Transdermal	-	N/A :: Transdermal :: continuous :: At night and in dusty/windy environments	None	Corneal status	STAT	STAT	ROUTINE	-
Tape eyelid closed at night	-	-	N/A :: - :: continuous :: If unable to close eye (use paper tape)	None	Corneal status	STAT	STAT	ROUTINE	-
Wraparound glasses/sunglasses	-	-	N/A :: - :: continuous :: During day for eye protection	None	Corneal status	-	ROUTINE	ROUTINE	-

3D. Pain Management¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	PO	-	650-1000 mg :: PO :: q6h :: 650-1000 mg PO q6h PRN; max 3000 mg/day	-	Hepatic disease	LFTs if prolonged use	ROUTINE	ROUTINE	ROUTINE	-
Ibuprofen	PO	-	400-600 mg :: PO :: q6h :: 400-600 mg PO q6h PRN with food	-	Renal disease, GI bleeding	Renal function	ROUTINE	ROUTINE	ROUTINE	-
Gabapentin (post-herpetic neuralgia)	PO	-	100-300 mg :: PO :: TID :: 100-300 mg TID; titrate as needed for Ramsay Hunt	-	Renal impairment	Sedation	-	ROUTINE	ROUTINE	-

3E. Lyme Disease Treatment (If Positive)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Doxycycline	PO	-	100 mg :: PO :: BID :: 100 mg PO BID × 14-21 days (isolated facial palsy)	Pregnancy, children <8	GI upset	-	STAT	ROUTINE	-
Ceftriaxone IV (CPT 96365)	IV	-	2 g :: IV :: daily :: 2 g IV daily × 14-21 days (if CNS involvement)	Cephalosporin allergy	Standard	-	STAT	-	-

3F. Physical Therapy¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Facial exercises	-	-	N/A :: - :: daily :: Mirror exercises, gentle facial movements	None	Start when recovery begins	-	ROUTINE	ROUTINE	-
Facial massage	-	-	N/A :: - :: daily :: Gentle massage to maintain muscle tone	None	Patient/family can perform	-	-	ROUTINE	-
Electrical stimulation	-	-	N/A :: - :: continuous :: Controversial; limited evidence	None	Not routinely recommended	-	-	EXT	-
Neuromuscular retraining	-	-	N/A :: - :: daily :: Specialized PT for synkinesis prevention	None	If incomplete recovery	-	-	ROUTINE	-

3G. Surgical Options (Refractory Cases)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Surgical decompression	-	>90% degeneration on ENoG within 14 days; controversial	-	Poor surgical candidate	Rarely performed; controversial benefit	-	-	EXT	-
Gold weight/platinum chain eyelid implant	-	Persistent lagophthalmos (>6-12 months)	-	None	Improves eye closure	-	-	EXT	-
Tarsorrhaphy	-	Persistent exposure keratopathy	-	None	Temporary or permanent	-	ROUTINE	ROUTINE	-
Static facial sling	-	Permanent severe palsy	-	None	Improves cosmesis	-	-	EXT	-
Hypoglossal-facial nerve anastomosis	-	Complete permanent paralysis	-	None	Restores tone and some movement	-	-	EXT	-
Cross-face nerve graft	-	Permanent paralysis, younger patients	-	None	Extended recovery time	-	-	EXT	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU	Indication
Ophthalmology	URGENT	URGENT	ROUTINE	-	Corneal exposure, inability to close eye, any eye pain/redness
ENT / Otolaryngology	-	ROUTINE	ROUTINE	-	Ramsay Hunt syndrome, atypical features, surgical consideration
Neurology	-	ROUTINE	ROUTINE	-	Atypical features, no recovery at 3-4 weeks, recurrent palsy
Physical therapy (facial)	-	-	ROUTINE	-	Begin when recovery starts; synkinesis prevention
Plastic surgery / Facial nerve specialist	-	-	EXT	-	Permanent paralysis, reconstructive options
Infectious disease	-	ROUTINE	ROUTINE	-	Lyme disease, atypical infection

4B. Patient/Family Instructions¶

Recommendation	ED	HOSP	OPD
Eye protection is CRITICAL - use lubricating drops frequently and ointment at night	STAT	STAT	ROUTINE
Tape eye closed or use patch at night to prevent corneal injury	STAT	STAT	ROUTINE
Start steroids as soon as possible (ideally within 72 hours of symptom onset)	STAT	STAT	ROUTINE
Most patients (70-80%) recover completely within 3-6 months	-	ROUTINE	ROUTINE
Recovery typically begins within 2-3 weeks; full recovery may take months	-	ROUTINE	ROUTINE
Return immediately if: eye pain, vision changes, redness, or discharge	STAT	STAT	ROUTINE
Examine ear daily for vesicles (if develops, call immediately - may be Ramsay Hunt)	ROUTINE	ROUTINE	ROUTINE
Follow up with neurologist or ENT if no improvement at 3-4 weeks	-	ROUTINE	ROUTINE
Do NOT massage face vigorously or use electrical stimulation without guidance	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Protect eye from wind, dust, and irritants	ROUTINE	ROUTINE	ROUTINE
Avoid rubbing the affected eye	ROUTINE	ROUTINE	ROUTINE
Consider humidifier at night	-	ROUTINE	ROUTINE
Chew carefully; may have food pocketing on affected side	-	ROUTINE	ROUTINE
Maintain diabetes control if diabetic (reduces risk and improves recovery)	-	ROUTINE	ROUTINE

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Stroke (central facial palsy)	Forehead SPARED (upper motor neuron pattern), other neurologic deficits	CT/MRI brain; emergent evaluation
Ramsay Hunt syndrome	Vesicles in ear canal/pinna, severe ear pain, may have hearing loss, vertigo	Otoscopic exam; VZV serology
Lyme disease	Endemic area, tick bite history, erythema migrans rash, may be bilateral	Lyme serology; LP if suspected
Acoustic neuroma	Gradual onset, hearing loss, tinnitus, other CN involvement	MRI with IAC protocol
Parotid tumor	Mass in parotid region, progressive weakness	CT/MRI parotid; biopsy
Guillain-Barré syndrome	Bilateral facial weakness, ascending weakness, areflexia	LP (albuminocytologic dissociation), NCS/EMG
Sarcoidosis (Heerfordt syndrome)	Bilateral, parotid swelling, uveitis, fever	Chest X-ray, ACE level, biopsy
Otitis media/Mastoiditis	Ear pain, fever, ear discharge, hearing loss	Otoscopic exam, CT temporal bone
Cholesteatoma	Chronic ear drainage, hearing loss, progressive	Otoscopic exam, CT temporal bone
Melkersson-Rosenthal syndrome	Recurrent facial palsy, facial edema, fissured tongue	Clinical triad
Diabetes mellitus	May present as Bell's palsy; higher incidence in diabetics	Glucose, HbA1c
HIV	Risk factors, other neurologic manifestations	HIV test
Multiple sclerosis	Other neurologic symptoms, white matter lesions	MRI brain

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
House-Brackmann grade	STAT	Daily	Each visit	-	Track recovery	Improvement over weeks	Consider imaging, EMG
Corneal status	STAT	Daily	Each visit	-	At each assessment	Clear cornea, no ulceration	Urgent ophthalmology
Eye closure (lagophthalmos)	STAT	Daily	Each visit	-	At each assessment	Improving closure	Increase eye protection
Blood glucose	STAT	Daily	Each visit	-	While on steroids	<200 mg/dL	Adjust DM medications
Vesicle check (ear)	STAT	Daily	Each visit	-	Daily × 7 days	None (Ramsay Hunt would require antivirals)	Add/continue antivirals
Recovery timeline	-	ROUTINE	ROUTINE	-	q2-4 weeks	Improvement by 3-4 weeks	Imaging, specialist referral
Synkinesis screening	-	-	ROUTINE	-	Starting at recovery	Absent	PT for neuromuscular retraining

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge from ED	Typical presentation, eye protection education, steroids prescribed, ophthalmology follow-up arranged if needed, close outpatient follow-up
Admit to hospital	Ramsay Hunt with severe symptoms, unable to protect eye, concern for stroke or other central cause, need for IV medications
Ophthalmology within 24-48h	Significant lagophthalmos, corneal exposure, any eye symptoms
Neurology follow-up	No improvement at 3-4 weeks, atypical features, recurrent episodes
ENT referral	Ramsay Hunt syndrome, surgical consideration, chronic cases

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Corticosteroids improve recovery	Class I, Level A	Scottish Bell's Palsy Study (Sullivan et al. NEJM 2007); Cochrane Reviews
Start steroids within 72 hours	Class I, Level A	Sullivan et al. NEJM 2007
Antivirals alone not effective	Class I, Level A	Cochrane Reviews 2015
Antivirals + steroids for severe Bell's	Class II, Level B	AAN Guidelines (Gronseth & Paduga, Neurology 2012)
Antivirals mandatory for Ramsay Hunt	Class I, Level B	Multiple studies; AAN Guidelines
Eye protection essential	Class I, Level C	Expert consensus
ENoG for prognosis in severe cases	Class II, Level B	Multiple studies
Surgical decompression controversial	Class III, Level U	Insufficient evidence
Most patients recover without intervention	Class I, Level A	Natural history studies (70-80% full recovery)

NOTES¶

Bell's palsy is a diagnosis of EXCLUSION - always evaluate for secondary causes
Forehead involvement (peripheral pattern) distinguishes from stroke (forehead spared = central pattern)
TIME-SENSITIVE: Steroids most effective if started within 72 hours of symptom onset
Eye protection is critical and often under-emphasized - corneal ulceration is preventable
Always examine the ear for vesicles (Ramsay Hunt syndrome requires antivirals)
Prognosis: 70-80% full recovery; 15-20% have residual weakness; 5% have severe sequelae
Poor prognostic factors: Complete paralysis (HB VI), no recovery by 3 weeks, age >60, diabetes, Ramsay Hunt syndrome
Synkinesis (aberrant regeneration) can develop during recovery - PT helps prevent/manage
Recurrent Bell's palsy is uncommon (~7%); warrants additional workup
Bilateral facial palsy is NOT Bell's palsy - requires workup for Lyme, GBS, sarcoidosis, etc.

CHANGE LOG¶

v1.0 (January 29, 2026) - Initial template creation - House-Brackmann scale included - Ramsay Hunt syndrome distinguished and treatment specified - Eye protection emphasized as critical component - Lyme disease workup for endemic areas - Surgical options for refractory cases