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Guidelines: Management of Bell Palsy: Clinical Practice Guideline
Guidelines: Management of Bell Palsy: Clinical Practice Guideline
Guidelines: Management of Bell Palsy: Clinical Practice Guideline
CME
CMAJ
John R. de Almeida MD MSc, Gordon H. Guyatt MD MSc, Sachin Sud MD MSc, Joanne Dorion PT BScPT,
Michael D. Hill MD, Michael R. Kolber MD MSc, Jane Lea MD, Sylvia Loong Reg PT, Balvinder K. Somogyi BSW,
Brian D. Westerberg MD MHSc, Chris White MD, Joseph M. Chen MD (Bell Palsy Working Group, Canadian
Society of Otolaryngology Head and Neck Surgery and Canadian Neurological Sciences Federation)
B
ell palsy is an idiopathic weakness or
end of article for competing
paralysis of the face of peripheral nerve interests.
origin, with acute onset. It affects 2030 We generated recommendations (specifically by
This article has been peer
persons per 100 000 annually, and 1 in 60 indi- rating the importance of outcomes, rating the confi- reviewed.
viduals will be affected over the course of their dence of effect estimates and grading recommenda-
Correspondence to:
lifetime. 1,2 The major cause of Bell palsy is tions) in accordance with methods proposed by the John de Almeida,
believed to be an infection of the facial nerve by Grading of Recommendations Assessment, De- john.dealmeida@utoronto.ca
the herpes simplex virus.3 As a result of this velopment and Evaluation (GRADE) system for CMAJ 2014. DOI:10.1503
viral infection, the facial nerve swells and is the development of clinical practice guideline rec- /cmaj.131801
compressed in its canal as it courses through the ommendations (Box 1).913 We applied the AGREE
temporal bone. appraisal tool for clinical practice guidelines.14
Recovery of facial nerve function is an
important outcome that guides treatment rec- Panel composition and organization
ommendations. The initial severity of facial A working group of 11 members was assembled
weakness provides valuable prognostic informa- under the auspices of the Canadian Society of Oto-
tion for facial recovery. Commonly used facial laryngology Head and Neck Surgery and the
grading instruments (e,g., HouseBrackmann Canadian Neurological Sciences Federation. The
and Sunnybrook scales) quantify the severity of group consisted of three methodologists (J.D.A.,
facial weakness.4,5 Patients with mild to moder- G.H.G., S.S.), three otolaryngology head and
ate paresis have higher rates of recovery than neck surgeons (J.D.A., B.D.W., J.M.C.), two neur-
those with severe or complete paresis. In a ologists (M.D.H., C.W.), one family physician
large, single-institution cohort study, recovery (M.R.K.), two facial nerve therapists (J.D., S.L.)
rates of 61% and 94% were documented in and one patient (B.K.S.). An additional methodolo-
patients with complete and incomplete paraly- gist (J.L.) was involved in the review process but
sis, respectively.6 not in developing the guideline recommendations.
Other important clinical outcomes exist in We developed the guidelines through a series of
Bell palsy. Up to 16% of those affected will four conference calls and extensive email corres-
have residual involuntary movements known as pondence between January 2010 and June 2012.
synkinesis,7 whereas others may have abnormal
lacrimation with eating, known as Bogorad syn- Management of conflicts of interest
drome (crocodile tears). Failure to protect the Group members disclosed financial and intellec-
cornea among patients who are unable to blink tual conflicts of interest. Each potential conflict
adequately may result in corneal ulceration and
permanent visual impairment. Those with resid- Key points
ual deficits may have long-term reduction in
quality of life and psychological distress.8 Preliminary assessment of a patient with Bell palsy should include
physical examination, to rule out other causes of facial weakness, and a
In this guideline, we review the evidence for grading of severity of weakness, to determine further treatment.
treatment of Bell palsy with corticosteroids and Unless contraindicated, corticosteroids should be given to all patients
antivirals, facial exercise, electrostimulation, with Bell palsy; antivirals may be considered for patients with severe to
physiotherapy and decompression surgery, as complete paresis.
well as the need for eye-protective measures, spe- Patients with incomplete eye closure should be given eye protection,
with lubricating drops and ointments, to prevent corneal damage.
cialist referral and further investigation in patients
For patients with persistent or progressive facial weakness, imaging of
with persistent and progressive weakness. the course of the facial nerve, referral to a specialist for further
This guideline is aimed at all health care diagnostic considerations and referral to a facial therapist for facial
providers, primarily front-line or primary care physiotherapy should be considered.
physicians who treat patients with Bell palsy.
2014 Canadian Medical Association or its licensors CMAJ, September 2, 2014, 186(12) 917
Guidelines
of interest was evaluated to determine whether it patient values and preferences. For treatments or
was acceptable or unacceptable (which would outcomes for which data were heterogeneous and
preclude participation). Panel members with outcome measures differed, we did not perform
acceptable conflicts of interest were permitted to meta-analysis. A description of the full methodol-
participate in collecting and interpreting evi- ogy and the complete guideline can be found in
dence but were not involved in deliberations for Appendix 1, available at www.cmaj.ca/lookup
recommendations related to their conflicts.15 /suppl/doi:10.1503/cmaj.131801/-/DC1.
Furthermore, the addition of antiviral therapy to was unable to achieve consensus regarding exer-
corticosteroid monotherapy is unlikely to be cise physiotherapy.
cost-effective.18 Patients who place a very high
value on avoiding synkinesis are likely to choose 6. We suggest exercise physiotherapy for patients
to use antivirals in addition to corticosteroids. with persistent weakness. (Weak recommenda-
tion: very low confidence in effect estimate.)
4. We suggest the combined use of antivirals and We identified one observational study evaluat-
corticosteroids in patients with severe to com- ing the use of exercise physiotherapy for patients
plete paresis. (Weak recommendation: moderate who did not have complete facial recovery.22 We
confidence in effect estimate.) rated our confidence in the effect estimate as very
With an RR for unsatisfactory recovery of low because of a serious risk of bias and imprecise
0.75 (95% CI 0.561.00), the NNT to prevent results. The single nonrandomized study evaluated
one unsatisfactory recovery is 14 in patients with two groups, one of which received exercise,
severe to complete paresis.16 The optimal dosing stretching and massage physiotherapy, and the
regimen is uncertain, although acyclovir 400 mg other of which did not. Patients in the physiother-
given five times daily or valacyclovir 1 g given apy group had significantly improved facial func-
three times daily is common in most studies. tion as measured by HouseBrackman scores
(mean difference 0.6, 95% CI 0.11.1).
5. We make no recommendation regarding the
use of exercise physiotherapy for acute Bell 7. We suggest against the use of electrostimula-
palsy of any severity. (No recommendation: very tion. (Weak recommendation: very low confi-
low confidence in effect estimate.) dence in effect estimate.)
Three studies were included in a systematic A systematic review identified four studies.2326
review evaluating the use of exercise physiother- Three of the studies (one comparing electrostimula-
apy; however, the confidence in effect estimates tion with massage;23 one comparing electrostimula-
was very low because of risk of bias, indirect- tion with corticosteroids;24 and one comparing heat,
ness and imprecision.1921 Given the heterogen- massage, exercises and electrostimulation with the
eous results in these studies, our working group same treatments excluding electrostimulation26)
Confidence in
Treatment Severity Recommendation Strength effect estimate
Corticosteroids Any severity We recommend the use of corticosteroids for all Strong Moderate
patients with Bell palsy.
Antivirals Any severity We recommend against antiviral treatment alone. Strong Moderate
Corticosteroids + Mild to moderate We suggest against the addition of antivirals to Weak Moderate
antivirals paresis corticosteroids for patients with mild to moderate
severity.
Severe to complete We suggest the combined use of antivirals and Weak Moderate
paresis corticosteroids in patients with severe to complete
paresis.
Exercise Acute; any severity We make no recommendation regarding the use Not Very low
physiotherapy of exercise physiotherapy for acute Bell palsy of applicable
any severity.
Chronic We suggest exercise physiotherapy for patients Weak Very low
with persistent weakness.
Electrostimulation Acute; any severity We suggest against the use of electrostimulation. Weak Very low
Surgical Severe to complete We suggest against the routine use of surgical Weak Very low
decompression paresis decompression.
Eye-protective Any severity, with We recommend the routine use of eye-protective Strong Very low
measures for incomplete eye measures for patients with incomplete eye closure.
incomplete eye closure
closure
Referral to Progressive cases We recommend referral to a specialist for patients Strong Very low
specialist with no improvement or progressive weakness.
Work-up for Progressive cases We recommend imaging to rule out neoplasms or Strong Very low
neoplasm alternative diagnoses for patients with no
improvement or progressive weakness.
showed no benefit in facial recovery. However, one sumed site of the lesion in Bell palsy, through a
randomized study showed significantly poorer middle cranial fossa surgical approach.27,28 One
facial recovery with electrostimulation than with nonrandomized study of patients who were
facial exercise.25 The available very-low-quality evi- offered surgery showed a significant benefit of
dence provides little support for electrostimulation; surgery relative to those treated medically (91% v.
in addition, the safety profile of such therapy is 42% chance of a fair recovery).27 Surgical decom-
unproven, and there is an added cost. pression has potentially serious risks, including
hearing loss (3%10% of patients),2729 further
8. We suggest against the routine use of surgical damage to the facial nerve (unknown prevalence)
decompression. (Weak recommendation: very and leaks of cerebrospinal fluid (4%).27 Patients
low confidence in effect estimate.) should consider this option only if they have
For studies identified in a systematic review, severe facial nerve degeneration on electroneu-
we had very low confidence in the effect estimates ronography, if they are willing to accept the surgi-
because of serious methodologic limitations cal risks and if the surgery is to be performed in
(specifically nonrandomization) and the impreci- an advanced treatment facility.
sion and indirectness of results. The surgical
approaches studied were heterogeneous, with only 9. We recommend the routine use of eye-protective
two of six studies involving decompression of the measures for patients with incomplete eye closure.
labyrinthine segment (meatal foramen), the pre- (Strong recommendation: very low confidence
in estimates.)
We identified no randomized or observational
Acute Bell palsy No eye- studies comparing visual outcomes with and
protective without eye-protective measures. We rated our
Adequate measures confidence in the effect estimate as very low
Assess eye closure needed because of the absence of available evidence.
Inadequate However, inadequate lubrication or hydration of
the cornea can lead to exposure keratitis, corneal
Assess severity ulceration and eventually loss of vision.
of paresis Eye-protective
measures needed
(strong 10. We recommend referral to a specialist for
recommendation) patients with no improvement or progressive
weakness. (Strong recommendation: very low
Mild to Severe to confidence in estimates.)
moderate complete paresis We identified no randomized or observational
studies comparing outcomes for patients with Bell
palsy who were and were not referred to a special-
Recommend Recommend ist. Therefore, our confidence in the effect estimates
corticosteroids corticosteroids Consider antivirals
(strong (strong (weak was very low. For patients with no improvement in
recommendation) recommendation) recommendation) facial nerve function or progression of facial nerve
paralysis, referral to an otolaryngologist may be
reasonable to confirm the diagnosis and to exclude
other conditions. Referral to a specialist may avoid
missed diagnoses of malignant skull-base neo-
Follow-up and
assess recovery plasms30 or benign facial nerve schwannomas,31
which may masquerade as Bell palsy. The possibly
catastrophic consequences of having a serious con-
dition that mimics Bell palsy, albeit rare, and the
Consider exercise unlikely serious harm associated with referral,
Complete Failure to recover physiotherapy
recovery or progressive motivate this strong recommendation.
(weak
weakness recommendation)
11. We recommend imaging to rule out neo-
plasms or alternative diagnoses for patients with
Refer to specialist no improvement or progressive weakness.
Imaging to rule out (Strong recommendation: very low confidence in
neoplasm
(strong recommendation) effect estimate.)
We identified no randomized or observational
studies investigating the role of imaging for neo-
Figure 1: Clinical decision-making algorithm for acute Bell palsy. plasms in patients with Bell palsy. Therefore, our
confidence in the effect estimate was very low. For position. Finally, Baugh and associates did not
patients with no response to initial treatment and make a recommendation about surgical decompres-
progressive facial paralysis, investigation for neo- sion. We felt that given the balance of possible
plasms along the course of the facial nerve should beneficial and harmful outcomes and the available
include imaging of the course of the facial nerve evidence, decompression should not be routinely
(brain stem, temporal bone, parotid gland) with performed.
either magnetic resonance imaging (MRI) or high- A Quality Standards Subcommittee of the
resolution computed tomography (CT). We found American Academy of Neurology issued a practice
no trials comparing various imaging techniques for parameter in 2001, concluding that there was insuf-
progressive facial nerve dysfunction, but each tech- ficient evidence to support the use of cortico-
nique has its own merits.32 MRI may be better steroids, antiviral agents or surgical decompression
suited to evaluating the brain stem, cerebellopon- for Bell palsy.35 A recent update of this guideline
tine angle, interfaces between bone and soft tissues, advocated the use of corticosteroids and concluded
and the parotid gland, whereas high-resolution CT that antivirals may be of modest benefit.36 Of two
may be more widely available and better suited for other treatment guidelines, one concluded that there
studying the intratemporal segment of the nerve.33 was insufficient evidence to give corticosteroids to
children37 and the other suggested use of cortico-
Implementation steroids on the basis of a narrative review of the
available evidence.38 The present guideline used the
Implementation of these guidelines will be facili- GRADE methodology and offers recommenda-
tated through publication and access to relevant tions addressing nonmedical therapeutic options
materials through the Canadian Society of Oto- that have been omitted from other guidelines.
laryngology Head and Neck Surgery and the
Canadian Neurological Sciences Federation. To Gaps in knowledge
aid in utilization of these guidelines, representa-
tives of pertinent health care stakeholders have Gaps in the available evidence have implications
been involved in the guideline-development for the current recommendations. Although mod-
process, and relevant professional organizations erate-quality evidence exists for medical treatment
were invited to review and/or endorse the guide- with corticosteroids and antiviral agents, our con-
line. The guideline will be updated in five years, fidence in estimates for all relevant patient-
with a plan to review the new interim evidence important outcomes from surgery and physiother-
and update the existing recommendations. apy was very low. According to the GRADE ap-
proach, recommendations should also be based on
Other guidelines evidence of values and preferences of patients
with the disease condition, as well as information
A concurrent guideline was recently published by about costs and resource allocation. However, we
the American Academy of Otolaryngology Head identified no studies for Bell palsy investigating
and Neck Surgery.34 That guideline, by Baugh and the values and preferences of patients and only
colleagues, had a similar scope and some similari- one study that examined costs of corticosteroids
ties in recommendations, but there were notable and antivirals for Bell palsy. Further research is
differences. The target audience included all treat- needed in these areas.
ing providers, whereas our guideline is aimed
mainly at primary care physicians. The other guide- Conclusion
line also focused on diagnostic work-up of Bell
palsy, whereas ours focused mainly on treatment Although many patients with Bell palsy will ex-
issues. We have recommended combined cortico- perience improvement in their facial nerve func-
steroid and antiviral therapy only for patients with tion without treatment, persistent facial weakness
severe to complete paralysis. Baugh and colleagues can have implications for quality of life. Estab-
recommended combined treatment as an option in lishing the correct diagnosis is imperative to avoid
all cases and did not consider specific subgroups missing another treatable condition. Choosing the
independently for these recommendations. We have correct treatment options for suitable patients can
also recommended that facial physiotherapy may optimize the likelihood of recovery. The current
be indicated for patients with long-standing paresis guidelines are based on the best available evi-
who have experienced no improvement, whereas dence for treatment and diagnosis of Bell palsy.
Baugh and colleagues did not consider this specific
subpopulation and did not make a recommendation References
1. Holland NJ, Weiner GM. Recent developments in Bells palsy.
for physiotherapy in acute cases. This difference BMJ 2004;329:553-7.
may be attributable to differences in the panel com- 2. Hauser WA, Karnes WE, Annis J, et al. Incidence and prognosis