What are the next steps for a patient finishing treatment for Bell's (Bell's palsy)?

Follow-Up Management for Bell's Palsy Patients

Patients who have completed treatment for Bell's palsy should be reassessed for incomplete recovery at 3 months after symptom onset, with referral to a facial nerve specialist if recovery is incomplete. 1

Assessment of Recovery

• Use the House-Brackmann scale to quantify facial nerve function:
  • Grade 1: Normal facial function
  • Grade 2: Mild dysfunction (slight asymmetry at rest)
  • Grade 3: Moderate dysfunction (obvious but not disfiguring difference)
  • Grade 4: Moderately severe dysfunction (obvious weakness/disfiguring asymmetry)
  • Grade 5: Severe dysfunction (barely perceptible movement)
  • Grade 6: Total paralysis (loss of tone, asymmetry, no movement) 1

Indications for Referral

Referral to appropriate specialists is necessary in the following situations:

1. New or worsening neurologic findings at any point (refer to neurologist)
2. Ocular symptoms developing at any point (refer to ophthalmologist)
3. Incomplete facial recovery 3 months after initial symptom onset (refer to facial nerve specialist) 2

Management of Complications

Eye Protection

• For patients with incomplete eye closure:
  • Artificial tears (during daytime)
  • Lubricating ophthalmic ointments (at night)
  • Eye patching or taping
  • Moisture chambers
  • Sunglasses for daytime protection 1

Functional and Psychological Impairment

• Long-term functional impairments may include:

  • Incomplete eye closure
  • Lacrimal dysfunction
  • Nasal airway obstruction
  • Oral incompetence 2

• Psychological support may be needed for:

  • Difficulty expressing emotion
  • Social interaction challenges
  • Stigmatization due to appearance 2

Reconstructive Options

For patients with incomplete recovery, discuss potential reconstructive procedures with a facial plastic and reconstructive surgeon:

• Eyelid weights
• Brow lifts
• Static and dynamic facial slings 2

Role of Physical Therapy

The evidence regarding physical therapy for Bell's palsy is inconclusive:

• No standardized therapy modalities or protocols exist

• Several approaches have been studied including:

  • Thermal treatment
  • Electrotherapy
  • Massage
  • Facial exercise
  • Biofeedback 2

• Mime therapy (massage, relaxation exercises, inhibition of synkinesis, and emotional expressive exercise) is the most common form but has limited evidence supporting its effectiveness 2

• Physical therapy may be beneficial specifically for patients with severe Bell's palsy (House-Brackmann grade V/VI) 3, though the American Academy of Otolaryngology-Head and Neck Surgery makes no formal recommendation due to limited evidence 2

Important Caveats

• Spontaneous recovery occurs in 70-80% of patients within 3 weeks to 3 months 4
• It can be difficult to separate the effects of physical therapy from spontaneous recovery 2
• A Cochrane systematic review found no significant difference between physical therapy and untreated control groups 2
• Consider psychological support or counseling for patients with persistent facial paresis/paralysis who may experience depression 2

Remember that timely follow-up and appropriate referrals are crucial for optimizing outcomes and quality of life for patients with Bell's palsy who have incomplete recovery.