Management of Bell palsy: clinical practice guideline

We identified no randomized or observational studies investigating the role of imaging for neo- plasms in patients with Bell palsy. Therefore, our confidence in the effect estimate was very low. For patients with no response to initial treatment and progressive facial paralysis, investigation for neo- plasms along the course of the facial nerve should include imaging of the course of the facial nerve (brain stem, temporal bone, parotid gland) with either magnetic resonance imaging (MRI) or high- resolution computed tomography (CT). We found no trials comparing various imaging techniques for progressive facial nerve dysfunction, but each tech- nique has its own merits.32 MRI may be better suited to evaluating the brain stem, cerebellopon- tine angle, interfaces between bone and soft tissues, and the parotid gland, whereas high-resolution CT may be more widely available and better suited for studying the intratemporal segment of the nerve.33 A concurrent guideline was recently published by the American Academy of Otolaryngology - Head and Neck Surgery.34 That guideline, by Baugh and colleagues, had a similar scope and some similari- ties in recommendations, but there were notable differences. The target audience included all treat- ing providers, whereas our guideline is aimed mainly at primary care physicians. The other guide- line also focused on diagnostic work-up of Bell palsy, whereas ours focused mainly on treatment issues. We have recommended combined cortico- steroid and antiviral therapy only for patients with severe to complete paralysis. Baugh and colleagues recommended combined treatment as an option in all cases and did not consider specific subgroups independently for these recommendations. We have also recommended that facial physiotherapy may be indicated for patients with long-standing paresis who have experienced no improvement, whereas Baugh and colleagues did not consider this specific subpopulation and did not make a recommendation for physiotherapy in acute cases. This difference may be attributable to differences in the panel com- position. Finally, Baugh and associates did not make a recommendation about surgical decompres- sion. We felt that given the balance of possible beneficial and harmful outcomes and the available evidence, decompression should not be routinely performed. Affiliations: Department of Otolaryngology, Head and Neck Surgery (de [John de Almeida]), Princess Margaret Hospital, University of Toronto, Toronto, Ont.; De