The ACEP Clinical Policies Committee regularly reviews guidelines published by other organizations and professional societies. Periodically, new guidelines are identified on topics with particular relevance to the clinical practice of emergency medicine but for which no ACEP policy is available. This article highlights recommendations for the diagnosis and management of Bell’s palsy, published by the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) in November 2013.
Your 12-hour shift is just about over when the nurse urgently calls you into a room for a code stroke. The patient is a 52-year-old man with a facial droop that his wife noticed about two hours prior to arrival. After being reassured by an unremarkable history and normal vitals, you examine the patient. The neurologic examination is normal except for mild, right-side facial nerve paralysis. You explain to him that he is experiencing a frequently encountered disease first described in the 1800s and that he has a good chance at recovery. You are about to prescribe the patient antiviral monotherapy when you recall the literature has gone back and forth in recent years. You excuse yourself from the room to review the latest recommendations.
You enter the search term “Bell’s palsy guideline” into tripdatabase.com and find a recent clinical guideline on the National Guideline Clearinghouse website from the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF).1 After reading the guideline, you determine that five days of 60 mg prednisone followed by a five-day taper is the way to go.
The methodology of the AAO-HNSF guideline included the review of 30 systematic reviews or meta-analyses, 49 clinical trials, and one relevant guideline. The diverse guideline committee included 17 members from various fields, such as surgery, neurology, primary care, and emergency medicine. They used the Guideline Implementability Appraisal and Extractor (GLIA) [PDF] to produce actionable statements and sort out any possible future implementation problems. The evidence reviewed was evaluated with a similar grading scale to that used by the American Academy of Pediatrics.
In contrast to the dichotomized GRADE scheme for recommendation statements, the authors of the AAO-HNSF guideline used a system allowing for a “strong recommendation,” “recommendation,” “option,” and “no recommendation.” The authors accounted for benefit and harm, value judgments, intentional vagueness, and the role of patient preference in each of their action statements.
With respect to patient history and physical examination, the authors give a strong recommendation for excluding identifiable causes of facial paresis or paralysis in those suspected of having Bell’s palsy. Their guideline recommends against ordering routine laboratory tests or routine diagnostic imaging for patients with Bell’s palsy and strongly recommends prescribing oral corticosteroids within 72 hours of symptom onset in those 16 years and older.
Based mainly on two randomized controlled studies, the authors recommend a 10-day course of either prednisolone 50 mg or prednisone 60 mg for five days followed by a five-day taper. The guideline authors also note that clinicians should explain the risks of oral corticosteroids when prescribing.
Regarding antiviral therapy, a strong recommendation against antiviral monotherapy is made, but the authors describe the use of combined oral corticosteroids and antiviral therapy as an “option.” They justify the optional addition of antiviral therapy to corticosteroid use by the relative low-risk profile for antiviral agents.
Lastly, there is a strong recommendation for providing eye care to patients with impaired eye closure. There is no evidence for this recommendation, but it is a strong recommendation based on expert opinion and preponderance of benefit over harm.
Dr. Gemme is a resident in emergency medicine at Alpert Medical School of Brown University, Providence, Rhode Island, and the 2013–2014 EMRA Representative to the ACEP Clinical Policies Committee.