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A New Guideline for Bell’s Palsy Previewed

A new guideline for the evaluation and treatment of Bell’s palsy will be published in Otolaryngology—Head and Neck Surgery in November. But Annual Meeting attendees got a sneak preview of the 11 new action statements Sunday morning.

“We focused on opportunities for improving the quality of care for patients with Bell’s palsy,” said Seth R. Schwartz, MD, MPH, Virginia Mason Medical Center, Seattle, and chair of the AAO-HNSF guideline task force. “This is not an all-encompassing publication that outlines every possible treatment for every possible scenario. We are concentrating on those areas with the greatest potential to improve treatment.”

The action statements are based on literature reviews and consensus among 17 panel members, including otolaryngologists, facial nerve and other specialists, family physicians, internists, nurses, physician assistants, and consumers. Each of the 11 statements is graded.

A strong recommendation means the benefits of the recommended approach clearly exceed the harms (or, in the case of a strong negative action statement, that the harms clearly exceed the benefits, and that the quality of the supporting evidence is high (grade A or B), Dr. Schwartz said. In some clearly identified circumstances, strong recommendation may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms.

A recommendation means the benefits exceed the harms (or, in the case of a recommendation against, that the harms exceed the benefits). But the quality of evidence not as high (grade B or C). In some clearly identified situations, action statements may be based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms.

An option means that either the quality of evidence is suspect (grade D) or that well-
done studies (grade A, B, or C) show little clear advantage to one approach versus another.

Strong Action Statements

The guideline defines Bell’s palsy as an acute, unilateral facial nerve paresis or paralysis that shows no improvement within 72 hours. The guideline includes eight action statements, starting with a complete physical exam that includes a detailed history for every patient who shows evidence of Bell’s palsy.

“The goal is to rule out any other cause,” said panel member Gregory Basura, MD, PhD, University of Michigan. “That’s where physical exam and history are so important. If this facial paralysis has been going on for three months, that’s important to know.”

Clinicians should not obtain routine laboratory testing for patients with new onset Bell’s palsy.

“We were very deliberate in our use of the word ‘routine’ in this action statement,” said Lisa Ishii, MD, MHS, Johns Hopkins University. “This gives the clinician some leeway in deciding what to do. But we found no benefit and potential harm in routine imaging as opposed to selective use of imaging.”

Oral steroids should be used with all patients older than 16 years within 72 hours of onset of symptoms. The action statement is based on randomized controlled clinical trials, which excluded children.

Action Statements and Options

Antiviral agents should not be used as monotherapy. But antivirals plus oral steroids are an option.

“An option means you sit down with the patient to discuss the pros and cons,” said Reginald F. Baugh, MD, University of Toledo, OH. “We included the option because there are small studies that suggest there may be some small benefit from combination therapy.”

All patients with impaired eye closure need eye protection. Otolaryngologists may automatically institute eye protection to avoid corneal or other optical damage, but the need may not be clear to other practitioners.

Avoid electrodiagnostic testing for patients with incomplete facial paralysis. There is no evidence that electrodiagnostic testing adds value and it exposes patients to potential harm. Electrodiagnostic testing is an option for patients with complete facial paralysis.

And all patients need follow up or referral if there are new or worsening neurological symptoms, ocular symptoms or incomplete facial recovery after three months.

“There are real psychological fears with Bell’s palsy, especially if it worsens or persists,” Dr. Baugh said. “This is an opportunity to make a difference in patients’ lives.”

 

No Action Statement

The guideline makes no recommendation in several areas, including the use of surgical decompression.

“The lack of bona fide evidence that surgical decompression will improve the natural history of Bell’s is why we made no action statement,” Dr. Basura said.

There was a similar lack of evidence for acupuncture and physical therapy.