Bell's palsy
Questionnaire/history:
Acute unilateral partial or complete lower motor neurone facial nerves palsy within less than 72 hours?
Drooping of the eyebrow?
Loss of nasolabial fold?
Corner of the mouth?
Mild pain in the ear/post-auricular region?
Numbness or disturbed taste on the side of the tongue?
Aged 15 to 45 years (peak incidence)?
Past medical history?
Current medication?
Known drug allergies?
Differential diagnosis:
Stroke: more acute onset; upper motor neurone signs with preservation of movement of forehead and eyebrows
Lyme disease: possible exposure?, consider treating/ testing
Infections (eg Ramsey Hunt syndrome): severe pain, vesicles in ear or mouth, hearing loss and imbalance suggests herpes zoster and requires specialist assessment - benefit from early antiviral treatment
Parotid tumours
Middle ear disease
Invasive skin cancer
Other
Prognosis:
Most begin to recover within 2-3 weeks, with complete recovery usual within 3-4 months
Even without intervention, 90% of those with incomplete paralysis and 70% with complete paralysis will recover completely within 6 months
Management:
Eye care: lubricating eye drops regularly in the day and ointment at night; tape eye shut with micropore overnight if unable to close eye
Steroids: convincing evidence effective, most effective if given within the first 72 hours, but some evidence to support treatment if patients present within 7 days
Prednisolone 50mg daily for 10 days most effective dose
Antivirals:
Antiviral therapy in idiopathic Bell’s palsy remains controversial. The latest Cochrane review Cochrane 2015 CD001869 shows some evidence of benefit in addition to steroids, but this is based on low-quality evidence. CKS states there may be a small benefit when used with steroid
Referral:
If any atypical features/red flags, including suspected Ramsay Hunt syndrome
If no improvement within 3 weeks, or incomplete recovery at 3 months
Surgery (based on a recommendation in BJGP):
Consider referral of all cases with a residual disability after 6 weeks to a plastic surgical facial reanimation service for consideration of surgical nerve grafting
Resource(s):
CKS 2019