Management of Chronic Bell's Palsy

Introduction to Management

• For patients with chronic Bell's palsy experiencing worsening symptoms, referral to a facial nerve specialist is strongly recommended as the primary intervention, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
• Bell's palsy accounts for approximately 70% of facial nerve palsies, according to the American Academy of Otolaryngology-Head and Neck Surgery 1

Diagnostic Approach

• A thorough history and physical examination focused on specific neurological findings should be the initial approach to facial paresthesia, with targeted diagnostic testing based on clinical suspicion rather than routine laboratory or imaging studies, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
• A systematic approach to laboratory testing should prioritize targeted diagnostics based on clinical suspicion rather than ordering panels routinely, as this maximizes diagnostic yield while minimizing unnecessary testing, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery and the National Comprehensive Cancer Network 2, 3, 4, 1
• First-line tests should include complete blood count, electrolytes and renal function, random glucose or HbA1c, and vitamin B12 levels when clinically indicated 1
• The following laboratory tests may be considered:
• Neuroimaging should not be performed routinely but reserved for specific indications, such as focal neurological deficits, sudden onset with concern for TIA/stroke, progressive symptoms, associated headache, altered mental status, or history of malignancy or immunocompromise 1
• Bone marrow biopsy components include aspirate and biopsy with immunohistochemistry, flow cytometry, cytogenetics, and is critical for diagnosis of leukemia, lymphoma, multiple myeloma 3, 8, 5

Treatment Options

• Eye protection is crucial for patients with impaired eye closure, including the use of artificial tears during the day, lubricating ointment at night, and taping eyelids closed if necessary 1
• Patients with dysphagia should be treated with supportive care and referred to a facial nerve specialist if swallowing difficulties persist beyond 3 months 1

Rehabilitation and Support

• Audiologic rehabilitation options include hearing aids or hearing assistive technology, contralateral routing of signal (CROS) hearing aids, and osseointegrated bone conductive devices 11, 12, 13, 14
• Vision rehabilitation involves compensatory strategies, environmental modifications, and assistive devices 11, 12, 13, 14
• Physical therapy may be particularly helpful for addressing synkinesis and improving facial symmetry in patients with more severe paralysis, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1
• Depression should be managed by referral to appropriate specialists, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
• Chronic pain, though rare, should be addressed by pain specialists, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
• For patients with impaired eye closure, consider referral to an ocular specialist for persistent eye symptoms, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
• Refer to a facial nerve specialist when there is incomplete recovery with residual facial weakness, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1