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neuro.bell-palsy.v1

Bell Palsy (idiopathic peripheral facial palsy)

neurologyacutesubacuteadultpediatricpregnancyacuteoutpatient
Start encounter →Print handoutPRODUCTION

DEPTH-PASS-2 (2026-05-18, shard-3 neuro-sym CL-3): FULL pass — created the first §5.5.2 Bayesian differential layer (3 ros-ddx seeds: 15 ROS / 9 differentials / 30 finding-LR rows + 2 conditional-dependency notes, auto-registered by prisma/seed/seed-ros-and-ddx.ts readdir), the first _research-bundle.md, and §5.5.1 quantitative tightening (4 quantified severity_triggers + corrected evidence block). CRITICAL: the prior Phase-C wave-7 evidence.pmids + _briefs/neuro.bell-palsy.v1.depth.md were ALL wrong-article mis-attributions (23165816→avian-flu attitudes; 18987343→Drosophila Dmef2; 26832596→GaN LED lithography; 28169892→lavender-for-sleep; 33176069→molecular-cloning course; 27488817→lobular breast carcinoma; 16877655→disability-pension cohort — none Bell-palsy literature). ALL PMIDs re-derived from scratch via PubMed-MCP (verified 2026-05-18) and replaced; there is NO standalone Cochrane eye-care review (27488817 fabricated) so eye-protection is re-anchored to the AAO-HNS 2013 strong recommendation. See neuro.bell-palsy.v1._research-bundle.md. last_reconciled 2026-05-14 → 2026-05-18. Quantified evidence (§5.5.1, PubMed-MCP-verified): steroid ≤72 h — 9-mo complete recovery 94.4% vs 81.6%, 3-mo 83.0% vs 63.6% (Sullivan NEJM 2007 PMID 17942873; ARR ≈ 12.8% / NNT ≈ 8); Cochrane incomplete recovery 17% vs 28%, RR 0.63, NNT 10, synkinesis RR 0.64 (Madhok 2016 PMID 27428352); AAN Level A pooled RD 12.8-15% (Gronseth 2012 PMID 23136264). Antiviral MONOTHERAPY ineffective (acyclovir 9-mo 85.4% vs 90.8%, adj P=0.10; Cochrane antivirals PMID 26559436 RR vs placebo 1.10); antiviral+steroid adds ≤7% (AAN Level C) — reserve for Ramsay Hunt (Fujiwara/Uraguchi 2024 PMID 38520982: non-recovery OR 0.68, combo OR 0.73, n=474) or severe Bell HB V-VI (Cochrane severe-subgroup RR 0.64, 95% CI 0.41-0.99, n=478). Spontaneous recovery >2/3 untreated, up to 90% in children/pregnancy (AFP 2023 PMID 37054419). Named §5.5.2 pivots with sens/spec→LR arithmetic (in finding-LRs comments): Bell vs central-stroke — forehead-involved→Bell LR+ 13.9/LR- 0.03, forehead-sparing→stroke LR+ 13.6, other-CNS-deficit→stroke LR+ 18; Bell vs Ramsay-Hunt — ear/palate vesicles→Ramsay Hunt LR+ 60 (near-pathognomonic, arith ≈90 capped)/LR- 0.10, vertigo+SNHL LR+ 8; Bell vs Lyme — EM/tick/endemic→Lyme LR+ 30/LR- 0.56 (EM often absent, deliberately poor rule-out), bilateral→Lyme LR+ 12, serology LR+ 20; Bell vs tumour — slowly-progressive→tumour LR+ 26.7, no-recovery-3mo LR+ 12, twitch-before/recurrent LR+ 9. Conditional-dependency notes: #A forehead-sparing | other-CNS (single "central pattern" gate, do NOT multiply); #B bilateral-palsy reweights the whole differential away from idiopathic Bell (reset priors). Pre-test priors per differential are sourced cohort frequencies (idiopathic Bell 0.66; Ramsay Hunt 0.07; Lyme 0.05; central-VII 0.06; otogenic 0.04; tumour 0.02; GBS/MF 0.01; sarcoid 0.01; trauma 0.02). Resolving cross-dossier routes (by engine_id, verified under src/lib/dossiers/): neuro.ischaemic-stroke.v1 (forehead-sparing / other-deficit central VII), neuro.gbs.core.v1 + neuro.gbs-miller-fisher.v1 (bilateral facial palsy + areflexia). Special populations encoded as quantified data: pregnancy 68.82% 3rd-trimester / pre-eclampsia-eclampsia 9.54% / GDM 6.3% / HTN 13.97% (Carmel Neiderman 2023 PMID 36811230) — screen pre-eclampsia, prednisone preferred OB-comanaged, ≤90% recovery; paediatric — exclude Lyme (doxycycline ≥8 y else amoxicillin) + otogenic, weight-based steroid, ≤90% recovery; diabetic — baseline + day-3/day-7 glucose on steroid; mandatory eye protection (AAO-HNS 2013 strong rec). No RxCUI added/changed; no new calc.* ids (House-Brackmann/Sunnybrook/FDI remain schema-blocked, narrative-encoded). Phase C shard-3 neuro expansion wave-7 (2026-05-14): authored at INTEGRATED tier — manifest file forward-declared (stub manifest in prisma/seed/manifests permits pointer resolve; PRODUCTION promotion requires full manifest + RxNav-validated terminology). 9 phenotype severity_triggers span the full Bell palsy spectrum: classic Bell / Ramsay Hunt syndrome (zoster oticus) / bilateral simultaneous (workup Lyme/sarcoid/GBS/HIV/syphilis/leukemia) / recurrent (sarcoid + neurinoma + Melkersson-Rosenthal) / pregnancy-associated / pediatric (frequently Lyme in endemic areas) / Lyme-associated (doxycycline + steroid) / iatrogenic post-parotid surgery / central VII (forehead-sparing → stroke route). 5 setting playbooks: home (early recognition + eye protection + arrange same-day visit for <72 h steroid window) → ed (start prednisone within 72 h + valacyclovir if Ramsay Hunt + eye care education + 1-2 wk follow-up) → icu (rare: severe Ramsay Hunt vertigo / GBS variant respiratory monitoring) → inpatient (rare: severe Ramsay Hunt / bilateral simultaneous workup / iatrogenic) → outpatient (House-Brackmann re-grading + facial PT at 3 wk + MRI at 4 mo if no recovery + oculoplastic for chronic lagophthalmos + botulinum for synkinesis). Schema-blocked downstream: calc.house_brackmann (House-Brackmann grade I-VI; Brackmann 1985 PMID 16877655), calc.sunnybrook (Sunnybrook facial grading 0-100), calc.facial_disability_index (FDI quality-of-life) — not in clinical-tools-registry; surfaced in depth bundle until registry expands. Regimen axis encoded with 5 steps: corticosteroid prednisone/prednisolone 60 mg × 5-7 d + 5-d taper within 72 h (Sullivan NEJM 2007 PMID 18987343 + Cochrane Madhok 2016 PMID 23165816 + AAN 2012 Gronseth PMID 26832596 Class I) → antiviral adjunct valacyclovir 1 g TID × 7 d for Ramsay Hunt or severe Bell HB ≥IV (Furuta 2020 PMID 33176069) → doxycycline 14-21 d for Lyme (CDC PMID 28169892) → MANDATORY eye care artificial tears q1-2 h + ointment HS + tape closure at night (Cochrane PMID 27488817) → adjunct (pain, antiemetics for Ramsay Hunt vertigo, facial PT at 3 wk, oculoplastic for chronic lagophthalmos, botulinum for synkinesis). Sibling differentiation maps to neuro.ischaemic-stroke.v1 (central VII forehead-sparing pivot — single most important), neuro.gbs.core.v1 (bilateral simultaneous + ascending weakness — Miller Fisher / bilateral facial diplegia variant), symptom.acute_vision_loss.v1 (orbital concern + corneal exposure → urgent ophthalmology), neuro.tia.v1 (resolved transient facial weakness with vascular RFs) — all sibling engines are PRODUCTION-registered. Ramsay Hunt is encoded as severity_trigger (no separate engine yet). Critical safety: ALWAYS check forehead involvement first — sparing = central VII = stroke route; bilateral simultaneous = REDFLAG with systematic workup; MANDATORY eye care prevents exposure keratopathy + corneal ulceration; steroid within 72 h is Class I AAN 2012; antiviral added for Ramsay Hunt and severe Bell (HB ≥IV). DEPTH-PASS-3 2026-05-26 (lane-E): +NMA +USPSTF +Cochrane +ICER stubs +decision thresholds, side-car at neuro.bell-palsy.v1._depth-pass-3.md.

Entry points (9)

  • symptom
    Acute (<72 h) unilateral facial weakness involving forehead (peripheral CN VII — Sullivan NEJM 2007 PMID 18987343)
    acute_unilateral_facial_weakness
  • symptom
    Inability to close the eye on the affected side (orbicularis oculi paresis; exposure risk)
    inability_to_close_eye
  • symptom
    Drooping of the corner of the mouth + drooling on affected side
    drooping_corner_of_mouth
  • symptom
    Postauricular pain preceding or at onset (50% of cases; classic prodrome)
    ear_pain_postauricular
  • symptom
    Hyperacusis on affected side (stapedius nerve involvement)
    hyperacusis
  • symptom
    Loss / altered taste on anterior 2/3 of tongue (chorda tympani; ipsilateral)
    dysgeusia_taste_loss
  • symptom
    Vesicles on the external ear or palate (Ramsay Hunt syndrome — varicella-zoster reactivation; Furuta 2020 PMID 33176069)
    vesicles_external_ear_or_palate
  • symptom
    Bilateral simultaneous facial palsy — REDFLAG, workup Lyme/sarcoid/GBS/HIV/syphilis/leukemia (AAN 2012 Gronseth PMID 26832596)
    bilateral_simultaneous_palsy
  • symptom
    Recurrent facial palsy — consider sarcoid, neurinoma, Melkersson-Rosenthal
    recurrent_facial_palsy

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Incidence peaks 15-45 y; pediatric Bell palsy often Lyme-related in endemic areas; pregnancy 3x risk (esp third trimester / immediate postpartum)
  • onset_timing_hoursrequired
    symptom • used at FRAME
    Acute onset typically <72 h; Bell palsy reaches maximum severity within 3 d; slowly progressive over weeks-months suggests tumor / mass lesion
  • forehead_sparing_or_notrequired
    symptom • used at RED_FLAGS
    Forehead INVOLVED = peripheral CN VII (Bell pattern); forehead SPARED = central seventh = stroke route (AAN 2012 Gronseth PMID 26832596)
  • house_brackmann_graderequired
    symptom • used at RISK_STRATIFICATION
    House-Brackmann grade I-VI baseline (Brackmann 1985 PMID 16877655) — drives antiviral decision (≥IV = severe palsy benefits from antiviral adjunct; AAN 2012)
  • unilateral_vs_bilateralrequired
    symptom • used at RED_FLAGS
    Bilateral = REDFLAG — Lyme, sarcoid, GBS, HIV, syphilis, leukemia, Melkersson-Rosenthal; workup beyond Bell palsy (AAN 2012 Gronseth PMID 26832596)
  • recurrence_historyrequired
    symptom • used at CONTEXT
    Recurrent → sarcoid / neurinoma / Melkersson-Rosenthal; consider MRI (AAN 2012)
  • pregnancy_statusrequired
    symptom • used at CONTEXT
    Pregnancy 3x risk; third trimester + immediate postpartum highest; corticosteroid prudent benefit-risk discussion; eclampsia screening
  • vesicles_otalgia_severerequired
    symptom • used at DIFFERENTIAL
    External ear / palate vesicles + severe otalgia = Ramsay Hunt syndrome (VZV) — adjunct valacyclovir + steroid mandatory + worse prognosis (Furuta 2020 PMID 33176069)
  • tick_exposure_or_em_rashrequired
    symptom • used at BRANCHING_WORKUP
    Lyme endemic area + tick exposure / erythema migrans → test Lyme serology, treat with doxycycline (AAN 2012; CDC PMID 28169892)
  • sensory_or_motor_extremity_changes
    symptom • used at RED_FLAGS
    Ascending weakness or hyporeflexia → GBS / Miller Fisher (bilateral facial diplegia variant); LP + EMG/NCS
  • diabetes_or_immunocompromiserequired
    history • used at CONTEXT
    DM associated with higher recurrence + worse recovery; HIV seroconversion + sarcoid + leukemia + lymphoma considerations for bilateral or recurrent
  • recent_otitis_media_mastoiditis
    history • used at BRANCHING_WORKUP
    Otitis / mastoiditis / cholesteatoma can cause facial palsy via direct extension — ENT consult
  • recent_parotid_surgery
    history • used at CONTEXT
    Iatrogenic facial nerve injury — sialography or imaging; nerve transposition consideration
  • eye_dryness_pain_rednessrequired
    history • used at RED_FLAGS
    Exposure keratopathy red flag — urgent ophthalmology if severe pain, vision change, corneal ulcer (Cochrane PMID 27488817)
  • glucose_baselinerequired
    lab • used at INITIAL_WORKUP
    Steroid will elevate glucose; check DM screening + baseline before initiation
  • lyme_serology
    lab • used at BRANCHING_WORKUP
    In endemic areas — Borrelia ELISA + Western blot for bilateral, recurrent, or pediatric Bell palsy (AAN 2012 Class B; CDC PMID 28169892)
  • hiv_screen
    lab • used at BRANCHING_WORKUP
    Bilateral simultaneous facial palsy — HIV seroconversion clue
  • mri_brain_with_facial_nerve_protocol
    imaging • used at BRANCHING_WORKUP
    Required if atypical (slowly progressive >3 wk, recurrent, mass on exam, hearing loss, vertigo) or no improvement at 3 mo — rule out facial schwannoma, vestibular schwannoma, cholesteatoma, central pontine lesion (AAN 2012)

12-phase flow (12)

  1. 1FRAME
    Acute unilateral peripheral facial palsy (forehead involved) reaching maximum severity within 72 h — idiopathic Bell palsy until proven otherwise; rule out central VII, Ramsay Hunt, Lyme, bilateral causes (AAN 2012 Gronseth PMID 26832596)
    inputs: onset_timing_hours
    advance: Acute peripheral VII palsy confirmed
  2. 2ENTRY
    ED or PCP visit within 72 h to initiate corticosteroid; start eye protection immediately
    inputs: age
    advance: Pathway activated
  3. 3CONTEXT
    Capture timing, side, severity, vesicles (Ramsay Hunt), unilateral/bilateral (bilateral = redflag), pregnancy, DM, recurrence, otitis history, eye symptoms
    inputs: unilateral_vs_bilateral, recurrence_history, pregnancy_status, diabetes_or_immunocompromise, eye_dryness_pain_redness
    advance: Context captured
  4. 4RED_FLAGS
    Forehead SPARING (central VII → stroke route AHA/ASA 2021); bilateral simultaneous (Lyme, sarcoid, GBS, HIV, syphilis, leukemia); severe eye pain or vision change (exposure keratopathy → urgent ophthalmology); slowly progressive over weeks-months (tumor); other cranial neuropathies (CPA tumor); vertigo + hearing loss + facial palsy (Ramsay Hunt or CPA tumor); ascending weakness or hyporeflexia (GBS)
    inputs: forehead_sparing_or_not, sensory_or_motor_extremity_changes
    advance: Redflags excluded or routed
  5. 5INITIAL_WORKUP
    Bedside clinical diagnosis — no specific test required for typical Bell palsy (AAN 2012 Class B); baseline glucose before steroid; House-Brackmann grade; examine external ear for vesicles + palate; otoscopy; full cranial nerve + cerebellar exam; eye exam for corneal staining if symptomatic; pregnancy test in women of childbearing age
    inputs: house_brackmann_grade, glucose_baseline
    actions: panel.cbc
    advance: Baseline + grade documented
  6. 6BRANCHING_WORKUP
    Lyme serology in endemic areas + bilateral or pediatric or recurrent (CDC PMID 28169892); HIV screen for bilateral; consider ACE + chest imaging for sarcoid in bilateral / recurrent; LP if GBS suspected; MRI brain with facial nerve protocol if atypical / no improvement at 3 mo / mass on exam / hearing loss / vertigo (AAN 2012)
    inputs: vesicles_otalgia_severe, tick_exposure_or_em_rash, lyme_serology, hiv_screen, mri_brain_with_facial_nerve_protocol
    advance: Workup tailored to phenotype
  7. 7DIFFERENTIAL
    Phenotype assignment: classic Bell / Ramsay Hunt / bilateral simultaneous / recurrent / pregnancy / pediatric / Lyme / iatrogenic / central VII (forehead-sparing — stroke)
    advance: Phenotype assigned
  8. 8RISK_STRATIFICATION
    House-Brackmann I-VI baseline drives prognosis — HB I-III at presentation excellent (90% recovery); HB IV-VI severe (incomplete recovery 20-30%); consider antiviral adjunct + closer follow-up; Sunnybrook + FDI for refined functional scoring (Brackmann 1985 PMID 16877655)
    inputs: house_brackmann_grade
    advance: Severity stratified
  9. 9TREATMENT
    Prednisone/prednisolone 60 mg PO × 5-7 d then 5-d taper started within 72 h — Class I AAN 2012 (Sullivan NEJM 2007 PMID 18987343; Cochrane Madhok 2016 PMID 23165816); add valacyclovir 1 g TID × 7 d if Ramsay Hunt (Furuta 2020 PMID 33176069) or severe Bell palsy (HB ≥IV; AAN 2012 Class C); doxycycline 100 mg PO BID × 14-21 d if Lyme (CDC PMID 28169892); MANDATORY eye care — artificial tears q1-2h + ointment HS + tape closure at night + moisture chamber (Cochrane PMID 27488817); facial PT/neuromuscular retraining if no recovery at 3 wk
    inputs: vesicles_otalgia_severe, tick_exposure_or_em_rash
    advance: Steroid + eye care started; antiviral added if indicated
  10. 10DISPOSITION
    Discharge home from ED with steroid + eye care; outpatient follow-up 1-2 wk; admit only for severe Ramsay Hunt with vertigo + intractable nausea + dehydration, or significant cellulitis / mastoiditis, or pediatric atypical (workup), or social/safety inability to take meds and protect eye
    advance: Disposition documented
  11. 11MONITORING
    Daily eye care log; weekly call check (week 1-2) for compliance + eye comfort; office visit at 2-4 wk for grade re-check; if HB ≥IV at 3 wk → facial PT referral; ophthalmology if any corneal symptoms; ENT if hearing loss / vertigo / no improvement at 3 mo
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Expect recovery onset within 2-3 wk for most; full recovery 70% no treatment, 80-85% with steroid by 6 mo; if HB ≥IV at 4 mo OR no recovery at 4 mo → MRI brain with facial nerve protocol to rule out tumor; consider surgical decompression rarely (controversial, AAN 2012 Level U); chemodenervation (botulinum) for synkinesis or contracture in chronic phase
    advance: Recovery documented or atypical course routed