HNY Policy and Pathway Repository - York

• Bell's Palsy is an idiopathic lower motor neurone palsy. Its onset is usually over a few hours or overnight. Its incidence is 25-35:100000.
• “Brow Test”
  • A patient suffering from Bell's Palsy cannot raise their brow.
  • A patient suffering from a Stroke can raise their brow.
• Reassure the patient that the prognosis is good. Most patients make a full recovery within 9 months.

Contact on-call ENT team for facial palsy and:

• Middle ear disease, Ramsay Hunt Syndrome (shingles of the ear canal), Parotid Neoplasm, CVA, Trauma.
• Children under 16 should always be referred via the on call ENT Dr.
• Patients who are pregnant or who have diabetes.

Refer urgently to neurology or ENT if there is:

• I. Any doubt regarding the diagnosis.
• II. Recurrent Bell's palsy.
• III. Bilateral Bell's palsy.
• If the cornea remains exposed after attempting to close the eyelid, refer urgently to ophthalmology via the on-call ophthalmology nurse.

• For people presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone. There is no consensus regarding the optimum dosing regimen, but options include:
  • Giving 25 mg twice daily for 10 days, or
  • Giving 60 mg daily for five days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred.
• Antiviral treatments are NOT recommended, either alone or in combination with prednisolone – antivirals can actually worsen symptoms.
• It would therefore be acceptable to start prednisolone and review the patient at 1 week (to ensure they are no worse) and then at 6 weeks (to ensure there is improvement). If there is no improvement at 6 weeks the patient should be referred routinely to ENT as above.
• The patient should be warned that dryness of the eye caused by it not closing properly can be a serious complication if left untreated. If there is incomplete eye closure the lid can be taped close with Micropore® at night and ocular lubricants, for example carbomer 980 eye drops 0.2%, should be given 4 times daily with liquid paraffin eye ointment at night.
• If the paralysis shows no sign of improvement after 1 month, or there is suspicion of a serious underlying diagnosis (e.g. cholesteatoma, parotid tumor, malignant otitis externa), refer urgently to ENT.

Information to include in referral letter

• If possible include a House Brackman score:

Grade	Definition
I	Normal symmetrical function in all areas
II	Slight weakness noticeable only on close inspection Complete eye closure with minimal effort Slight asymmetry of smile with maximal effort Synkinesis barely noticeable, contracture, or spasm absent
III	Obvious weakness, but not disfiguring May not be able to lift eyebrow Complete eye closure and strong but asymmetrical mouth movement with maximal effort Obvious, but not disfiguring synkinesis, mass movement or spasm
IV	Obvious disfiguring weakness Inability to lift brow Incomplete eye closure and asymmetry of mouth with maximal effort Severe synkinesis, mass movement, spasm
V	Motion barely perceptible Incomplete eye closure, slight movement corner mouth Synkinesis, contracture, and spasm usually absent
VI	No movement, loss of tone, no synkinesis, contracture, or spasm

 

• Relevant past medical / surgical history
• Current regular medication
• Smoking status

Patient information leaflets/ PDAs

• http://www.patient.co.uk/health/bells-palsy

References

• NEJM Oct 2007 Sullivan F. „Early Treatment with Prednisolone or Acyclovir in Bell's Palsy‟ NEJM 2007 Oct(16);357:1598-1607
• http://cks.nice.org.uk/bells-palsy updated 2012