NICE Guidance- Bell’s Palsy episode or peripheral facial palsy
Description
My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE CKS Bell’s palsy, last revised in May 2019. It covers the diagnosis, management and prescribing information.
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NICE CKS on Bell’s palsy can be found here:
https://cks.nice.org.uk/topics/bells-palsy/
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Transcript
Welcome to a new episode of the Clinical Guidelines in Primary Care podcast. My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I will go through the NICE Clinical Knowledge Summary on Bell’s palsy, which was last revised in May 2019. It covers the diagnosis, management and prescribing information. As ever, all information is correct at the time of recording. I hope that you enjoy the episode.
(Bell's palsy: Summary)
- Bell's palsy is an acute, unilateral facial nerve weakness or paralysis of rapid onset (less than 72 hours) and unknown cause.
- The Herpes simplex virus, varicella zoster virus, and autoimmunity may contribute to it, but the significance of these factors remains unclear.
- Bell's palsy affects 20–30 people per 100,000 each year. It most common between 15 and 45 years of age.
- Complications include eye injury, facial pain, dry mouth, intolerance to loud noises, abnormal facial muscle contraction during voluntary movements, and psychological sequelae.
(Diagnosis)
- A diagnosis of Bell's palsy can be made when no other medical condition is found to be causing facial weakness or paralysis.
- Routine laboratory tests and diagnostic imaging are not required in primary care for new-onset Bell's palsy.
- We must take a history and perform a focused examination of the scalp, ears, mastoid region, parotid glands, oral cavity, eyes, and cranial nerves to identify features suggesting an alternative cause of facial palsy.
- Typical symptoms include:
- Rapid onset (less than 72 hours).
- Facial muscle weakness (almost always unilateral) involving the upper and lower parts of the face. This causes a reduction in movement on the affected side, often with drooping of the eyebrow and corner of the mouth and loss of the nasolabial fold.
- Ear and postauricular region pain on the affected side.
- Difficulty chewing, dry mouth, and changes in taste.
- Incomplete eye closure, dry eye, eye pain, or excessive tearing.
- Numbness or tingling of the cheek and/or mouth.
- Speech articulation problems, drooling.
- Hyperacusis.
§ Features atypical of Bell's palsy require referral for exclusion of an alternative diagnosis.
§ These atypical features are:
- Insidious and painful onset. Gradual progression is more likely to be associated with a neoplastic or infectious cause of facial palsy.
- A progressive and prolonged (more than 3 months) duration of symptoms with frequent relapses (indicative of a neoplastic process).
- Predisposing factors for facial palsy, for example, previous stroke, brain tumour, parotid tumour, skin cancers of the head and face, or facial trauma.
- Systemic illness or fever.
- Vestibular or hearing abnormalities (other than hyperacusis), otorrhoea, diplopia or dysphagia.
- Sparing of forehead movement (which may indicate an upper motor neurone lesion such as stroke) and bilateral signs (may be indicative of Lyme disease or sarcoidosis). Lower motor neurone lesions (such as Bell's palsy) do not spare the upper face.
- A recurrent episode.
- Paralysis of individual branches of the facial nerve or other cranial nerve involvement.
- Parotid gland masses, vesicular skin rashes, and lesions suggestive of skin cancer.
[Management (From age 16 years onwards)]
In terms or management for those aged 16 years onwards:
- We must reassure the person that the prognosis is good. Most people with Bell's palsy make a full recovery within 3–4 months.
- To manage Bell’s palsy:
- We must give advice that:
- The person should keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired. If they experience eye irritation, pain, or vision changes, they should seek immediate medical advice.
- If facial weakness or paralysis affects eating, suggest using a straw for liquids and advise eating soft foods.
- We must offer the person written advice on the condition
- In terms of medication
- For people presenting within 72 hours of the onset of symptoms, the prescription of prednisolone should be considered.
- There is no consensus regarding the optimum dosing regimen, but options include:
- Giving 50 mg 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 alone are not recommended.
- Antiviral treatment in combination with a corticosteroid may be of small benefit, but we must seek specialist advice if this is being considered.
(Referral)
- Referral to a facial nerve specialist should be arranged if there is doubt about the diagnosis or there is:
- No improvement after 3 weeks of treatment.
- Incomplete recovery 5 months after the onset of initial symptoms- such as symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking) 5 months or more after the onset of Bell's palsy for neurological assessment and possible treatment.
- Any atypical features.
- Referral to an ophthalmologist is needed if the person has eye symptoms (for example pain, irritation, or itch).
- Referral for further support or counselling should be considered if there are emotional consequences of persistent facial paralysis or paresis.
- We must refer urgently to an appropriate specialist people with facial nerve palsy and:
- Worsening of existing neurologic findings, or new neurologic findings.
- Features suggestive of an upper motor neurone cause (for example limb paresis, facial paraesthesia, other cranial nerve involvement, postural imbalance).
- Features suggestive of cancer (for example, gradual onset of symptoms, persistent facial paralysis for more than 6 months, pain in the distribution of the facial nerve, head or neck lesion suggestive of cancer, history of head and neck cancer, hearing loss on the affected side).
- Systemic or severe local infection.
- Trauma.
Differential diagnosis
- Other causes of facial weakness and paralysis include:
- Stroke — forehead spared, extremities often affected.
- Brain tumour — possible history of cancer, mental state changes, gradual onset.
- Traumatic injury to the facial nerve (for example, basal skull fracture, or as a consequence of surgery) — suggested by history and signs such as bruises or scars.
- Facial nerve tumour, skin cancer, parotid tumours — may only affect certain branches of the facial nerve. Onset of symptoms is gradual. May be painful.
- Infectious causes:
- Herpes simplex — history of fever and malaise.
- Lyme disease — may cause bilateral symptoms.
- Otitis media — otalgia, conductive hearing loss, gradual onset.
- Mastoiditis —mastoid region tender or swollen.
- Cholesteatoma — foul smelling otorrhoea and hearing loss
- Ramsay Hunt syndrome — pain followed by vesicular rash on the pinna, or in the ear canal or pharynx. Associated with sensorineural hearing loss.
- Encephalitis/meningitis — headache, neck stiffness.
- HIV — fever, malaise, CD4 count.
- Syphilis — other neurological and skin symptoms and signs.
- Glandular fever — malaise, few distinguishing characteristics.
- Diabetes — history of, or other symptoms and signs of diabetes.
- Multiple sclerosis — intermittent symptoms and additional neurological symptoms.
- Guillain-Barré — ascending paralysis, weakness of hands and feet, then trunk.
- Sarcoidosis — symptoms may be bilateral, suggestive laboratory test results (angiotensin-converting enzyme level).
- Arteriovenous malformation.
Extra guidance- basis for recommendation
Antiviral treatment combined with corticosteroids
- Combined corticosteroid and antiviral treatment is not routinely recommended for people with Bell's palsy, because there is insufficient evidence to support its use compared with corticosteroids alone.
- A Cochrane systematic review (with a search date of October 2014) showed that when compared with corticosteroids alone, low-quality evidence indicated a benefit of combined antiviral and corticosteroid treatment in terms of incomplete recovery
- Also, published guidelines differ in their recommendations on combined corticosteroid and antiviral treatment.
- A Canadian clinical practice guideline advises not to combine corticosteroids and antiviral treatment for people with mild to moderate severity Bell's palsy, but suggests their use if there is severe to complete paresis
- The American Academy of Otolanryngology-Head and Neck Surgery guideline development group gives clinicians the option of offering antiviral treatment in addition to oral corticosteroids within 72 hours for people with Bell's palsy, on the basis that there is a small potential improvement in the function of the facial nerve, while acknowledging that there is no proven benefit from large, high-quality clinical trials.
- The guideline development subcommittee of the American Academy of Neurology concluded that, for people with new-onset Bell's palsy, combination treatment with corticosteroids and antivirals should be offered because of the possibility of a modest improvement in recovery compared with corticosteroids alone. They noted, however, that any potential benefit is small and not well established.
- Although the risks and adverse effects of antiviral treatment are minimal NICE CKS recommends seeking specialist advice if combination treatment is being considered. There is uncertainty about the optimal antiviral drug and dosing regimen
This is the end of this episode of the Clinical Guidelines in Primary Care podcast. I hope that you have enjoyed this episode and I hope that you will join me in the next one. Thank you for listening and goodbye.
