Patient handout

Bell Palsy (idiopathic peripheral facial palsy)

PRODUCTION

1. Your condition

This handout is for bell palsy (idiopathic peripheral facial palsy). Your care team identified this based on: acute (<72 h) unilateral facial weakness involving forehead (peripheral cn vii — sullivan nejm 2007 pmid 18987343).

Other reasons your team may use this plan: inability to close the eye on the affected side (orbicularis oculi paresis; exposure risk); drooping of the corner of the mouth + drooling on affected side; postauricular pain preceding or at onset (50% of cases; classic prodrome).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
prednisone	60 mg PO daily × 5-7 d, then 5-d taper (e.g., 50/40/30/20/10 mg)	PO	daily	Sullivan NEJM 2007 PMID 18987343 — prednisolone alone improved recovery vs placebo + improved over acyclovir alone; Cochrane Madhok 2016 PMID 23165816 — high-quality evidence; AAN 2012 Gronseth PMID 26832596 Class I
prednisolone	60 mg PO daily × 5-7 d, then 5-d taper	PO	daily	Sullivan NEJM 2007 used prednisolone; equivalent to prednisone in non-hepatic-disease patients; preferred in hepatic dysfunction
dexamethasone	10 mg PO/IV × 1, then 8 mg q8h × 24 h, then taper	PO/IV	q8h then taper	Less placental transfer than prednisone (preferred in pregnancy when steroid indicated); collaborate OB-GYN

Plan: Bell palsy acute Rx — corticosteroid + eye care core; antiviral for Ramsay Hunt or severe Bell; doxycycline for Lyme (AAN 2012 Gronseth PMID 26832596)

3. When to call your provider

Contact your care team if any of the following happen:

No improvement at 3 wk → facial PT + close follow-up
No improvement at 4 mo → MRI brain to rule out tumor; consider neurology + ENT
Worsening at any point → MRI brain + neurology consult (atypical for Bell — consider tumor or other diagnosis)
Severe corneal ulcer → urgent ophthalmology
Recurrent facial palsy → MRI + sarcoid + Lyme workup; Melkersson-Rosenthal consideration

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Ramsay Hunt syndrome (herpes zoster oticus) — facial palsy + vesicles in ear canal / concha / palate + severe otalgia ± vertigo ± sensorineural hearing loss; worse prognosis than Bell (Furuta 2020 PMID 33176069)
Bilateral simultaneous facial palsy — REDFLAG, workup Lyme / sarcoid / GBS-Miller Fisher / HIV seroconversion / syphilis / leukemia / lymphoma / Melkersson-Rosenthal (AAN 2012 Gronseth PMID 26832596)
Iatrogenic facial nerve injury after parotid surgery / temporal bone surgery / cosmetic surgery — direct nerve injury; nerve transposition consideration
Central VII palsy — forehead SPARING (frontalis preserved bilaterally due to bilateral cortical input); lower facial weakness from cortical / brainstem / corona radiata stroke (AHA/ASA 2021 BE-FAST)(life-threatening)
Forehead-sparing-or-other-deficit STROKE route (quantified pivot): forehead-involved entire-hemiface weakness → peripheral Bell (LR+ ≈ 13.9, LR- ≈ 0.03 from sens 0.97/spec 0.93; see neuro.bell-palsy.v1.finding-lrs.ts row 1). Forehead-SPARING (frontalis preserved by bilateral cortical input) → central VII / ischaemic stroke (LR+ ≈ 13.6 from sens 0.95/spec 0.93), and any CONCOMITANT limb/speech/sensory deficit → stroke LR+ 18 — these two are conditionally dependent (combine as a single "central pattern" gate, do NOT multiply; see conditional-dependency note #A). Action: do NOT treat as Bell, do NOT give prednisone, activate stroke pathway and route to neuro.ischaemic-stroke.v1 (time-critical thrombolysis/EVT window).(life-threatening)
Bilateral-simultaneous palsy GBS/Miller-Fisher route (quantified prior-shift): bilateral simultaneous facial palsy REWEIGHTS the whole differential away from idiopathic Bell (bilateral → against-Bell LR+ 0.05; conditional-dependency note #B — reset priors, do NOT multiply the shared observation). Bilateral + generalized areflexia → GBS/Miller-Fisher LR+ 15 (LR- 0.30); bilateral → Lyme LR+ 12; bilateral + uveoparotid → sarcoid LR+ 10. Action: if bilateral + areflexia/ataxia/ascending weakness → LP (albuminocytologic dissociation) + NCS + anti-GQ1b, route to neuro.gbs.core.v1 / neuro.gbs-miller-fisher.v1; else workup Lyme/sarcoid/HIV/syphilis/leukaemia.

5. Follow-up

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

6. Sources

Guideline: 2013 AAO-HNS Clinical Practice Guideline: Bell’s Palsy (Baugh, PMID 24189771) + 2012 AAN Evidence-Based Guideline Update: steroids and antivirals for Bell palsy (Gronseth, PMID 23136264) + Sullivan Scottish Bell Palsy Trial NEJM 2007 (PMID 17942873) + Cochrane corticosteroids (Madhok 2016, PMID 27428352) + Cochrane antivirals (Gagyor/Madhok, PMID 26559436); Lyme floor IDSA/AAN/ACR 2021 (Lantos, DOI 10.1093/cid/ciaa1215; AAN parameter PMID 17522387 retired)