eMedicine Specialties > Emergency Medicine > Neurology

Bell Palsy: Follow-up

Author: Bruce Lo, MD, Medical Director, Sentara Norfolk General Hospital; Assistant Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School
Contributor Information and Disclosures

Updated: Oct 27, 2009

Follow-up

Inpatient & Outpatient Medications

  • Prednisone at an initial dose of 1 mg/kg/d up to 60 mg should be strongly considered within 72 hours of onset of symptoms if no contraindications exist.
    • Prednisone is a potent drug with a potential for side effects. While older studies are mixed in showing efficacy,19 2 recent, double-blinded, randomized controlled trials showed benefit if treatment was started within 72 hours.20,21
    • The best prednisone regimen for Bell's palsy is a short burst (up to 10 d), but steroid taper may also be used.
    • Caution should be given to patients who are immunocompromised, pregnant, or have poorly controlled diabetes, severe peptic ulcer disease, an active infection, sarcoidosis, or sepsis.
    • High-dose steroids (>120 mg/d of prednisone) have been safely used to treat Bell's palsy in patients with diabetes;25,26 however, optimal dosing has not been established. Caution should be given in these cases due to the risk of hyperglycemia.
  • Consider using antivirals within 72 hours if there is a high suspicion for HSV or VZV as a cause.
    • Administer acyclovir (Zovirax) 800 mg PO 5 times/d for 10 d; 20 mg/kg in patients younger than 2 years. Evidence supports HSV as a major cause of Bell's palsy. However, evidence of efficacy with acyclovir has been mixed.22 A recent trial showed no additional benefit with the addition of acyclovir to prednisolone.20
    • Valacyclovir (Valtrex), 500 mg PO twice a day for 5 days, may be used instead of acyclovir. Although more expensive, this may lead to better compliance. If VZV is the cause, higher doses may be needed (1000 mg PO tid). However, evidence of efficacy with valacyclovir has been mixed.16,22,23 A recent trial showed no additional benefit with the addition of high-dose valacyclovir to prednisolone.21 Because of increased cost and increased risk of side effects with higher doses, valacyclovir cannot be routinely recommended at this time.

Complications

  • Most patients with Bell's palsy recover without any cosmetically obvious deformities; however, approximately 5% are left with an unacceptably high degree of sequelae.
  • Incomplete motor regeneration
    • The largest portion of the facial nerve comprises efferent fibers that stimulate muscles of facial expression. Suboptimal regeneration of this portion results in paresis of all or some of these facial muscles.
    • This manifests as (1) oral incompetence, (2) epiphora (excessive tearing), and (3) nasal obstruction.
  • Incomplete sensory regeneration
    • Dysgeusia (impairment of taste) may result.
    • Ageusia (loss of taste) may result.
    • Dysesthesia (impairment of sensation or disagreeable sensation to normal stimuli) may result.
  • Aberrant reinnervation of the facial nerve
    • During regeneration and repair of the facial nerve, some neural fibers may take an unusual course and connect to neighboring fibers. This aberrant reconnection produces unusual neurologic pathways.
    • When voluntary movements are initiated, they are accompanied by involuntary movements (eg, the movement of a closed eye following that of the uncovered one). These involuntary movements accompanying voluntary movement are termed synkinesis.

Prognosis

  • The natural course of Bell's palsy varies from early complete recovery to substantial nerve injury with permanent sequelae. Prognostically, patients fall into 3 groups:
    • Group 1 - Complete recovery of facial motor function without sequelae
    • Group 2 - Incomplete recovery of facial motor function, but no cosmetic defects are apparent to the untrained eye
    • Group 3 - Permanent neurologic sequelae that are cosmetically and clinically apparent
  • Patients who experience incomplete facial paralysis during the acute phase have an excellent prognosis for full recovery. Patients demonstrating complete paralysis are at higher risk for severe sequelae.7
  • Other factors that determine worsening prognosis are history of recurrence,27 diabetes,25 increased age, longer onset of time to recovery, presence of postauricular pain, abnormal taste, stapedius reflex, and tearing.7
  • Of patients with Bell's palsy, 85% achieve complete recovery, 10% have some persistent asymmetry of facial muscles, and 5% experience severe sequelae.
  • The prognosis in pregnant women with Bell's palsy may be slightly worse than it is in nonpregnant women with Bell's palsy.12
  • Bilateral Bell's palsy is thought to share the same prognosis as unilateral Bell's palsy.8

Patient Education

  • Eye care
    • Protect the eye from foreign objects and sunlight.
    • Keep the eye well lubricated.
    • Educate the patient to report new ocular findings such as pain, discharge, or visual changes.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Bell Palsy.
 


More on Bell Palsy

Overview: Bell Palsy
Differential Diagnoses & Workup: Bell Palsy
Treatment & Medication: Bell Palsy
Follow-up: Bell Palsy
Multimedia: Bell Palsy
References
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References

  1. Teixeira LJ, Soares BG, Vieira VP, Prado GF. Physical therapy for Bell s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. Jul 16 2008;CD006283. [Medline].

  2. Cardoso JR, Teixeira EC, Moreira MD, Fávero FM, Fontes SV, Bulle de Oliveira AS. Effects of exercises on Bell's palsy: systematic review of randomized controlled trials. Otol Neurotol. Jun 2008;29(4):557-60. [Medline].

  3. He L, Zhou MK, Zhou D, Wu B, Li N, Kong SY, et al. Acupuncture for Bell's palsy. Cochrane Database Syst Rev. Oct 17 2007;CD002914. [Medline].

  4. Seok JI, Lee DK, Kim KJ. The usefulness of clinical findings in localising lesions in Bell's palsy: comparison with MRI. J Neurol Neurosurg Psychiatry. Apr 2008;79(4):418-20. [Medline].

  5. Katusic SK, Beard CM, Wiederholt WC, Bergstralh EJ, Kurland LT. Incidence, clinical features, and prognosis in Bell's palsy, Rochester, Minnesota, 1968-1982. Ann Neurol. Nov 1986;20(5):622-7. [Medline].

  6. Adour K, Wingerd J, Doty HE. Prevalence of concurrent diabetes mellitus and idiopathic facial paralysis (Bell's palsy). Diabetes. May 1975;24(5):449-51. [Medline].

  7. Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;4-30. [Medline].

  8. Kim YH, Choi IJ, Kim HM, Ban JH, Cho CH, Ahn JH. Bilateral simultaneous facial nerve palsy: clinical analysis in seven cases. Otol Neurotol. Apr 2008;29(3):397-400. [Medline].

  9. Keane JR. Bilateral seventh nerve palsy: analysis of 43 cases and review of the literature. Neurology. Jul 1994;44(7):1198-202. [Medline].

  10. Gilden DH. Clinical practice. Bell's Palsy. N Engl J Med. Sep 23 2004;351(13):1323-31. [Medline].

  11. Yanagihara N. Incidence of Bell's palsy. Ann Otol Rhinol Laryngol Suppl. Nov-Dec 1988;137:3-4. [Medline].

  12. Vrabec JT, Isaacson B, Van Hook JW. Bell's palsy and pregnancy. Otolaryngol Head Neck Surg. Dec 2007;137(6):858-61. [Medline].

  13. Smouha EE, Coyle PK, Shukri S. Facial nerve palsy in Lyme disease: evaluation of clinical diagnostic criteria. Am J Otol. Mar 1997;18(2):257-61. [Medline].

  14. Unlu Z, Aslan A, Ozbakkaloglu B, Tunger O, Surucuoglu S. Serologic examinations of hepatitis, cytomegalovirus, and rubella in patients with Bell's palsy. Am J Phys Med Rehabil. Jan 2003;82(1):28-32. [Medline].

  15. Morgan M, Moffat M, Ritchie L, Collacott I, Brown T. Is Bell's palsy a reactivation of varicella zoster virus?. J Infect. Jan 1995;30(1):29-36. [Medline].

  16. Kawaguchi K, Inamura H, Abe Y, Koshu H, Takashita E, Muraki Y. Reactivation of herpes simplex virus type 1 and varicella-zoster virus and therapeutic effects of combination therapy with prednisolone and valacyclovir in patients with Bell's palsy. Laryngoscope. Jan 2007;117(1):147-56. [Medline].

  17. Völter C, Helms J, Weissbrich B, Rieckmann P, Abele-Horn M. Frequent detection of Mycoplasma pneumoniae in Bell's palsy. Eur Arch Otorhinolaryngol. Aug 2004;261(7):400-4. [Medline].

  18. Yanagihara N, Yumoto E, Shibahara T. Familial Bell's palsy: analysis of 25 families. Ann Otol Rhinol Laryngol Suppl. Nov-Dec 1988;137:8-10. [Medline].

  19. Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004;(4):CD001942. [Medline].

  20. [Best Evidence] Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med. Oct 18 2007;357(16):1598-607. [Medline].

  21. Engstrom M, Berg T, Stjernquist-Desatnik A, Axelsson S, Pitkäranta A, Hultcrantz M, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. Nov 2008;7(11):993-1000. [Medline].

  22. Allen D, Dunn L. Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004;CD001869. [Medline].

  23. Hato N, Yamada H, Kohno H, Matsumoto S, Honda N, Gyo K. Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol. Apr 2007;28(3):408-13. [Medline].

  24. Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Apr 10 2001;56(7):830-6. [Medline].

  25. Kanazawa A, Haginomori S, Takamaki A, Nonaka R, Araki M, Takenaka H. Prognosis for Bell's palsy: a comparison of diabetic and nondiabetic patients. Acta Otolaryngol. Aug 2007;127(8):888-91. [Medline].

  26. Saito O, Aoyagi M, Tojima H, Koike Y. Diagnosis and treatment for Bell's palsy associated with diabetes mellitus. Acta Otolaryngol Suppl. 1994;511:153-5. [Medline].

  27. Sathirapanya P, Sathirapanya C. Clinical prognostic factors for treatment outcome in Bell's palsy: a prospective study. J Med Assoc Thai. Aug 2008;91(8):1182-8. [Medline].

  28. O'Rahilly R, Muller F. Basic Human Anatomy: A Regional Study of Human Structure. Philadelphia, Pa: WB Saunders Co; 1983:391-98.

  29. Olson WH, Brumback RA, Christoferson LA. Practical Neurology for the Primary Care Physician. Springfield, Ill: Thomas Books; 1981:262.

  30. [Best Evidence] Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis. BMJ. Sep 7 2009;339:b3354. [Medline].

  31. de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. Sep 2 2009;302(9):985-93. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Bruce Lo, MD, Medical Director, Sentara Norfolk General Hospital; Assistant Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School
Bruce Lo, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Medical Society of Virginia, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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