Bell's palsyMANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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376 items

☷ Legend

01Approach to the Critical Patient/attcp24

Immediate priorities

›Stabilization and exclusions

›Airway compromise

›If stridor or inability to handle secretions, airway escalation

›Stroke exclusion

›If acute focal deficits beyond facial nerve, stroke pathway

›CNS infection exclusion

›If fever and meningismus, CNS infection pathway

›Temporal bone trauma exclusion

›If head trauma and ear bleeding, temporal bone fracture pathway

›Eye protection urgency

›If incomplete eyelid closure, immediate corneal protection

Time critical decision points

›High risk features requiring alternate diagnosis

›Gradual progressive weakness beyond 72 hours

›MRI brain and internal auditory canal consideration

›Recurrent ipsilateral facial palsy

›Tumor or structural lesion evaluation

›Bilateral facial palsy

›Lyme disease and Guillain Barre syndrome evaluation

›Vesicular rash or severe otalgia

›Ramsay Hunt syndrome consideration

›Facial palsy with parotid mass

›Neoplasm evaluation

›Facial palsy with hyperacusis and taste change

›Peripheral facial nerve localization support

02History/hx42

Key history elements

›Symptom characterization

›Onset timing

›Hours to 1 to 2 days typical

›Progression pattern

›Maximal weakness within 72 hours typical

›Laterality

›Unilateral typical

›Prior episodes

›Recurrence risk factor for alternate etiology

›Pain

›Retroauricular pain common early

›Eye symptoms

›Dryness

›Foreign body sensation

›ENT symptoms

›Hyperacusis

›Taste disturbance anterior tongue

›Reduced lacrimation

›Recent viral syndrome

›Upper respiratory infection prodrome

›Rash history

›Ear or oral vesicles

›Tick exposure

›Travel or outdoor exposure in endemic region

›Systemic symptoms

›Fever

›Arthralgias

›Weight loss

›Immunocompromise

›HIV risk factors

›Transplant or steroids

›Pregnancy status

›Third trimester and postpartum risk

Pitfalls

›Historical red flags

›Limb weakness or numbness

›Central cause consideration

›Dysarthria or dysphagia

›Brainstem process consideration

›Diplopia or vertigo

›Posterior circulation process consideration

›Hearing loss or severe vertigo

›Ramsay Hunt or other otologic pathology consideration

03Physical Exam/exam39

Focused neuro and head and neck

›Facial nerve distribution

›Forehead involvement

›Inability to raise eyebrow supports peripheral palsy

›Eye closure strength

›Lagophthalmos severity grading

›Smile and nasolabial fold

›Asymmetry and droop severity grading

›Synkinesis baseline

›Involuntary co contraction if chronic or prior episodes

›Taste and lacrimation adjuncts

›Anterior tongue taste change support

›Dry eye risk assessment

›Cranial nerve screen

›Pupils and extraocular movements

›Abnormalities support central process

›Hearing gross assessment

›Asymmetry supports Ramsay Hunt or other lesion

›Palate elevation and tongue deviation

›Abnormalities support brainstem lesion

›Skin and ear exam

›External ear canal and pinna

›Vesicles support Ramsay Hunt syndrome

›Oral mucosa

›Vesicles or ulcers support herpes zoster

›Parotid gland exam

›Mass supports neoplasm

›Eye exam

›Corneal integrity

›Fluorescein staining if exposure symptoms

›Conjunctival injection

›Exposure keratopathy indicator

Severity grading

›Facial palsy grading tools

›House Brackmann grade

›Grade I normal

›Grade VI total paralysis

›Sunnybrook score

›Resting symmetry

›Voluntary movement

›Synkinesis

04Differential Diagnosis/ddx37

Life threatening and must not miss

›Central causes

›Ischemic stroke involving corticobulbar pathways

›ICD-10 I63

›Intracranial hemorrhage

›ICD-10 I61

›Brainstem tumor or mass

›ICD-10 D49.6

›Neuromuscular causes

›Guillain Barre syndrome

›ICD-10 G61.0

›Myasthenia gravis

›ICD-10 G70.00

Peripheral facial palsy causes

›Idiopathic facial nerve palsy

›Bell palsy

›ICD-10 G51.0

›SNOMED CT concept facial nerve palsy idiopathic

›Infectious

›Herpes zoster oticus

›Ramsay Hunt syndrome

›ICD-10 B02.21

›Lyme disease

›Neuroborreliosis facial palsy

›ICD-10 A69.2

›Otitis media or mastoiditis associated palsy

›ICD-10 H66 and H70

›HIV associated facial palsy

›ICD-10 B20

›Structural

›Parotid malignancy or benign tumor

›ICD-10 C07 and D11

›Temporal bone fracture

›ICD-10 S02.19

›Inflammatory and systemic

›Sarcoidosis

›ICD-10 D86

›Multiple sclerosis

›ICD-10 G35

05Laboratory Tests/lt18

When labs are indicated

›Targeted testing strategy

›Typical isolated Bell palsy

›No routine labs needed

›Clinical diagnosis supported by peripheral pattern

›Lyme risk or endemic exposure

›Two tier serology

›EIA or ELISA screening

›Immunoblot confirmation per local protocol

›Vesicular rash or immunocompromise

›Varicella zoster virus testing if diagnosis unclear

›PCR from lesion if present

›Systemic features or bilateral palsy

›Basic labs for alternative etiologies

›Complete blood count for infection or hematologic concern

›Electrolytes for systemic illness context

›Diabetes risk or severe palsy

›HbA1c consideration

›Prognosis association with diabetes

06Diagnostic Tests/dt29

Scoring Systems

›Severity and prognosis tools

›House Brackmann grading

›Higher grade at presentation predicts slower recovery

›Grade V to VI supports consideration of adjunct antiviral therapy

›Sunnybrook facial grading system

›Baseline documentation for follow up comparison

›Synkinesis tracking during recovery

MRI

›Indications for MRI brain and internal auditory canal

›Atypical features

›Gradual progression beyond 72 hours

›No improvement by 3 months

›Recurrent facial palsy

›Tumor or structural lesion evaluation

›Multiple cranial neuropathies

›Inflammatory or infiltrative process evaluation

›Findings compatible with Bell palsy

›Facial nerve enhancement possible but nonspecific

›Indications for CT head or temporal bone

›Trauma history

›Temporal bone CT for suspected fracture

›Otitis media complications

›Mastoiditis evaluation if severe otalgia and fever

›Concern for stroke or hemorrhage

›Noncontrast CT head if central features

Ultrasound

›Point of care applications

›Parotid and neck ultrasound

›Palpable mass evaluation support

›No routine role for Bell palsy diagnosis

›Use limited to alternate diagnoses

07Disposition/dispo17

Site of care decisions

›Disposition criteria

›Outpatient management typical

›Stable vitals

›Isolated peripheral facial palsy pattern

›Eye protection plan established

›Admission or observation indications

›Inability to protect cornea

›Severe lagophthalmos with corneal injury

›Suspected stroke or CNS infection

›Neuroimaging and specialist evaluation needs

›Severe pain with Ramsay Hunt syndrome

›Hydration and analgesia needs

›Immunocompromised with suspected disseminated infection

›IV therapy consideration

›Follow up timing

›Primary care or ENT within 1 week

›Ophthalmology within 24 to 72 hours if incomplete eye closure

08Treatment/t71

First line therapy

›Corticosteroids

›Prednisone or prednisolone initiation within 72 hours

›Prednisone 60 mg PO daily for 5 days

›Then 40 mg PO daily for 5 days

›Total 10 day course

›Prednisone 50 mg PO daily for 10 days alternative

›No taper option per local practice

›Key counseling

›Greatest benefit when started early

›Avoid delay for imaging in typical cases

›Eye protection

›Artificial tears

›Preservative free drops every 1 to 2 hours while awake

›Increase frequency with dryness

›Lubricating ointment

›At bedtime

›Use with taping or moisture chamber

›Eyelid taping

›Nightly if incomplete closure

›Ensure lashes not abrading cornea

›Ophthalmology referral triggers

›Corneal pain

›Same day evaluation

›Decreased vision

›Same day evaluation

›Corneal staining

›Prompt evaluation

Adjunctive antiviral therapy

›Antivirals with steroids

›Consider for severe palsy

›House Brackmann V to VI

›Shared decision making

›Valacyclovir

›1000 mg PO three times daily for 7 days

›Renal dose adjustment required

›Acyclovir alternative

›400 mg PO five times daily for 10 days

›Adherence limitations

›Evidence framing

›Steroids high benefit for complete recovery

›Class I recommendation common in neurology guidelines

›Antiviral incremental benefit small and greatest in severe cases

›Class IIb recommendation reasonable

Ramsay Hunt syndrome pathway

›Herpes zoster oticus management

›Antiviral plus corticosteroid recommended

›Valacyclovir 1000 mg PO three times daily for 7 to 10 days

›Start as early as possible

›Prednisone regimen as above

›Use with antiviral

›Analgesia

›Acetaminophen weight based or standard dosing

›Avoid exceeding daily maximum

›NSAID if no contraindication

›GI and renal risk review

›ENT follow up

›Hearing symptoms or vertigo

›Urgent referral

Symptom control and rehab

›Pain control

›Acetaminophen

›650 to 1000 mg PO every 6 to 8 hours as needed

›Max 4000 mg per 24 hours

›Ibuprofen

›400 mg PO every 6 to 8 hours as needed

›Max 2400 mg per 24 hours typical

›Facial physical therapy

›Consider for severe palsy or prolonged recovery

›Guidance to avoid excessive forced exercises early

›Synkinesis management in chronic phase

›Specialist referral consideration

›Antibiotics

›Not indicated for idiopathic Bell palsy

›Use only if otitis media or other bacterial diagnosis present

09Special Populations/sp33

Pregnancy

›Pregnancy considerations

›Higher incidence in third trimester and early postpartum

›Preeclampsia association consideration

›Steroid use

›Prednisone and prednisolone generally compatible with pregnancy

›Lowest effective duration

›Antiviral use

›Valacyclovir generally considered acceptable when indicated

›Obstetric input for individualized risk

›Alternative diagnosis vigilance

›Headache or hypertension

›Preeclampsia evaluation

Geriatric

›Older adult considerations

›Higher baseline stroke risk

›Lower threshold for neuroimaging if atypical features

›Steroid adverse effects

›Hyperglycemia monitoring plan

›Delirium risk counseling

›Eye complication risk

›Early ophthalmology if severe lagophthalmos

Pediatrics

›Pediatric considerations

›Common infectious differentials

›Lyme disease in endemic regions

›Otitis media related palsy

›Steroid dosing

›Prednisone 1 mg per kg per day

›Max 60 mg per day

›5 days then taper 5 days common regimen

›Antiviral use

›Consider in severe palsy or zoster suspicion

›Weight based dosing per local pediatric formulary

›Safeguarding eye care

›Caregiver instruction for drops and taping

10Background/b32

Epidemiology

›Population features

›Most common cause of acute unilateral peripheral facial paralysis

›Incidence commonly cited around 15 to 30 per 100000 per year

›Age distribution

›Broad distribution with peak in adults

›Risk factors

›Pregnancy

›Diabetes mellitus

›Recent viral illness

Pathophysiology

›Mechanism

›Acute inflammation and edema of facial nerve

›Compression within facial canal

›Ischemia and conduction block

›Viral reactivation hypothesis

›Herpes simplex virus type 1 association proposed

›Clinical localization

›Lower motor neuron pattern

›Forehead involvement due to peripheral lesion

Therapeutic Considerations

›Rationale for steroids

›Reduction of nerve edema and inflammation

›Improved odds of complete recovery when early

›Rationale for antivirals

›Possible viral contribution

›Greatest theoretical benefit in severe palsy

›Prognosis counseling

›Majority achieve substantial recovery

›Early improvement predicts better outcome

›Poor prognostic factors

›Complete paralysis at onset

›Older age

›Diabetes mellitus

›Delayed steroid initiation

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Bell palsy is a weakness of the facial nerve causing one sided facial droop

›Medications

›Take steroid exactly as prescribed

›Take antiviral if prescribed

›Eye care

›Artificial tears often during the day

›Ointment at night

›Tape eyelid closed during sleep if it does not fully close

›Expected course

›Symptoms often worsen for up to 2 to 3 days then stabilize

›Improvement often begins within weeks

›Follow up

›Primary care or ENT within 1 week

›Eye doctor urgently if eye pain or vision changes

›Return to emergency care now for

›New arm or leg weakness or numbness

›Trouble speaking or trouble walking

›Severe headache

›Fever or stiff neck

›New double vision

›Worsening vision

›Eye pain or inability to keep eye moist

›Spreading rash or ear vesicles with severe dizziness

12References/r9

Guidelines and key sources

›Evidence base

›American Academy of Neurology guideline on steroids and antivirals for Bell palsy

›Steroids early for improved complete recovery

›Otolaryngology guidance on eye protection in facial nerve palsy

›Corneal protection as highest priority

›Infectious disease guidance for Lyme associated facial palsy testing and treatment

›Two tier serology and region specific epidemiology

›Source specification

›Clinical management system formatting and nesting requirements

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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