Diagnostic Workup and Treatment for Bell's Palsy

Initial Assessment

A thorough history and physical examination are essential to exclude identifiable causes of facial paresis/paralysis, as Bell's palsy is a diagnosis of exclusion, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Key diagnostic criteria for Bell's palsy include acute onset (<72 hours) of unilateral facial weakness/paralysis, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1, 3
No identifiable cause is a key criterion for diagnosing Bell's palsy, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 1

The patient's advanced age increases stroke risk, which must be ruled out, according to the American Academy of Otolaryngology-Head and Neck Surgery 2
Bilateral facial weakness is rare in Bell's palsy and suggests alternative diagnosis, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 3
New or worsening neurologic findings at any point require further investigation, according to the American Academy of Otolaryngology-Head and Neck Surgery 2
Slow progression of symptoms (>72 hours) suggests neoplastic or infectious cause, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 4

Routine laboratory testing is NOT recommended for typical presentations of Bell's palsy, according to the American Academy of Otolaryngology-Head and Neck Surgery 5
Diagnostic imaging is NOT routinely recommended for typical Bell's palsy, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 5
Consider MRI of head, orbit, face and neck with and without contrast to rule out stroke and other causes, as recommended by the American College of Radiology 6
CT head may be appropriate if MRI is contraindicated or unavailable, according to the American College of Radiology 6

Prescribe oral steroids within 72 hours of symptom onset, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
Do NOT prescribe antiviral therapy alone, as strongly recommended against by the American Academy of Otolaryngology-Head and Neck Surgery 2
Implement eye protection for patients with impaired eye closure, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 5

Reassess or refer to a facial nerve specialist if new or worsening neurologic findings develop at any point, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
Consider electrodiagnostic testing only if complete facial paralysis is present, according to the American Academy of Otolaryngology-Head and Neck Surgery 2