RELEVANT PATIENTS, GROUP(S) OR SUBGROUPS OF PEOPLE. THIS MAY INCLUDE DETAILS SUCH AS AGE RANGE, GENDER, COEXISTING DIAGNOSES, AND REASONS FOR THERAPY: The target population is inclusive of both adults and children presenting with Bell s palsy THE IMPORTANT HEALTH-RELATED BENEFITS AND HARMS YOU ARE INTERESTED IN, FOR EXAMPLE, IMPROVEMENTS IN SYMPTOMS OR PROBLEMS WITH DIAGNOSIS: Q1. What are the benefits and risks of steroid use in children with Bell s palsy? Information is limited, as children were excluded from most treatment trials of new-onset Bell s palsy. Several studies indicate that the prognosis of untreated Bell s palsy in children is better and that children show higher rates of spontaneous recovery than do adults; therefore, the potential benefit of corticosteroid treatment is inconclusive.1 Compelling data are lacking for steroid use in children, and the need for steroid treatment is unclear.2,3 The GDG identified 2 systematic reviews/meta-analyses that specifically addressed oral corticosteroid use in children.4,5 Pitaro and Daniel4 performed a systematic review of children diagnosed with new-onset Bell s palsy treated with steroids and found no controlled trials on the subject. Studies identified for inclusion in the systematic review had low evidence levels and concluded that the evidence for the use of steroids in children is inconclusive.The systematic review by Salman and MacGregor5 sought to include pediatric trials, including patients with Bell s palsy younger than 16 years who were treated with steroids. Identified studies exhibited flawed randomization methodologies and reported both children and adults together. Only 1 included study exclusively involved children, and it was not placebo controlled. The remainder of the identified trials did not perform separate analyses for the pediatric group. The systematic review concluded that there was no firm evidence for the routine use of steroids in children with new-onset Bell s palsy. Despite the absence of quality trials supporting steroid use in children, given the presumed similar disease process of Bell s palsy in adults and children, as well as the generally favorable benefit-harm ratio of steroid therapy, oral steroids may be considered in pediatric patients with a large role for caregiver involvement in the decision-making process.

Q2. Are their benefits associated with surgical facial nerve decompression? Surgical decompression of the facial nerve in patients with Bell s palsy has been used in select cases as an option to improve the chances of recovery of facial nerve function. There has been some controversy about the effectiveness of surgery to improve outcomes in Bell s palsy. This controversy stems from the good outcomes for patients with incomplete paralysis, the lack of large trials, the diversity of patients in existing trials (e.g., degree and duration of paralysis), the variable surgical approaches that have been reported, and the lack of effectiveness in some trialsrelative to natural history. Previous systematic reviews have grouped these diverse trials and concluded a lack of definitive benefit of surgery.6,7 A few select trials have studied patients early after onset of symptoms and have surgically decompressed the facial nerve in the area most likely to be affected in Bell s palsy. Although small in size, these trials have demonstrated effectiveness at improving the percentage of patients recovering to normal or near-normal facial function. Based on the flawed nature of much of the literature and the significant risks and cost of surgical decompression of the facial nerve, despite a potential small benefit of surgical decompression, the AAO-HNSF guideline panel could make no recommendation for or against its use. Most patients are not surgical candidates due to the excellent overall rates of recovery, ranging from approximately 70% with no treatment to 94% with steroids.8,9 Electrodiagnostic testing in patients with complete paralysis can identify a subset of patients with an increased likelihood of poor recovery.8 Specifically, patients with complete paralysis, greater than 90% reduction in amplitude on electroneuronograph (ENoG) testing relative to the unaffected side of the face, and absent volitional nerve activity on EMG are less likely to recover spontaneously or with medical treatment alone.10,11,12 In this small group of patients, observation or medical treatment alone leads to relatively poor recovery rates, and therefore, given the significant morbidity of permanent facial paralysis, more aggressive intervention could be considered. Early animal studies showed that decompression of the facial nerve within 12 days of injury improved regeneration of the nerve.13 The same rationale has been applied to patients with Bell s palsy as the underlying pathophysiology is likely related to neural edema that compresses the nerve in an anatomically confined bony canal. In most cases of Bell s palsy, the site of constriction is thought to be at the most narrow portion of the facial nerve canal: the labyrinthine segment starting at the meatal foramen.11,12,14 The meatal foramen is at the lateral internal auditory canal where the labyrinthine segment of the facial nerve exits the internal auditory canal and rises to the geniculate ganglion.Most studies reporting on decompression of the mastoid segment of the facial nerve (distal to the presumed site of injury in the labyrinthine segment) have failed to show any benefit of surgery. A Cochrane review by McAllister et al7 searched for all randomized or quasi-randomized controlled trials involving any surgical intervention for Bell s palsy. Only 2 studies met inclusion criteria for this meta-analysis.15,16 The pooled data from these studies did not show improved facial nerve outcomes for patients with surgical decompression of the facial nerve, although both studies used transmastoid decompression only.7 May et al17 and Aoyagi et al18 also failed to show benefit of facial nerve decompression via a transmastoid approach. Yanagihara et al19 reported improvement with transmastoid decompression, but the geniculate and lateral labyrinth segment were also decompressed. This extended access via the transmastoid route required disarticulation of the incus, which risks creating conductive hearing loss. In 1981, Fisch20 reported his experience with decompression of the labyrinthine segment via a middle fossa approach. The middle fossa approach requires a craniotomy but allows for removalof the bone surrounding the facial nerve at the meatal foramen and fallopian canal without affecting the structures of hearing. The decompressed group had a better return of function (79% for patients with 95%-100% reduction in amplitude, 93% for those with 90%-94% reduction in amplitude), while only 64% of control patients who were not decompressed regained normal function. A subsequent study by Gantz et al10 provides the most compelling evidence in support of middle fossa decompression of the facial nerve in Bell s palsy. This was a multicentered, case-control study. Inclusion criteria included ENoG testing with .90% reduction in amplitude on the affected side and no voluntary EMG activity. Testing and treatment were done at least 3 but no more than 14 days after the onset of acute facial paralysis. In the surgical group, 31 of 34 (91%) patients achieved a House-Brackmann facial nerve outcome of I/II compared with only 15 of 36 (42%) of patients in the steroid-only control group (P = .0002). No high-level evidence is available to confirm the findings of Gantz et al.10 Kim et al21 reported on a case series in which 11 of 13 patients who underwent middle fossa decompression achieved a House-Brackmann score of I or II. All patients in this study had ENoG reduced to 10% of the contralateral value, although the average time to surgery was 37 days (range, 8-75 days) after symptom onset.21 Another case series by Bodenez et al22 reported that 13 of 13 patients with ENoG reduced to 10% of the contralateral nerve recovered to House-Brackmann III after a subpetrosal approach, which also allows for bony removal at the meatal foramen and geniculate ganglion. Nerve decompression procedures took place a mean of 5 weeks after onset of Bell s palsy. Middle fossa decompression of the facial nerve does have substantial costs and rare but serious risks.23 These include conductive or sensorineural hearing loss; injury to the facial nerve; risk of cerebrospinal fluid leak; infection; risks of temporal lobe retraction such as temporary or permanent aphasia, seizures, and stroke; and nonspecific risks with general anesthesia.24-26 A hospital stay including at least 1 day in the intensive care setting is generally necessary with the attendant costs.There are logistical complexities in the expeditious evaluation of patients who may qualify for surgery. Patients with complete facial paralysis need to have electrodiagnostic testing (ENoG and EMG) performed after day 7 but before 14 days after onset of paralysis. If patients meet the electrodiagnostic criteria spelled out in the Gantz et al10 trial, surgery must be performed within 14 days of symptom onset for optimal effectiveness. Therefore, it is the responsibility of clinicians who adopt surgical decompression as part of their practice to develop facilitated pathways of referral to permit the proper evaluation and management of patients within this restricted timeframe.10 In addition, there are currently few clinicians able to perform this procedure. Due to the technical difficulty and paucity of patients who meet criteria for surgical candidacy, few centers in the United States perform a high volume of middle fossa surgery for Bell s palsy. In a 2011 survey ofactive members of the American Neurotology and Otological Societies, only 22% of respondents reported performing more than 5 middle fossa decompression surgeries for Bell s palsy in the prior 10 years of practice, and only 4% had performed more than 10 in the same period.27 Despite the infrequent performance of the surgery, most middle cranial fossa surgeons have the expertise to perform decompression of the facial nerve. The literature is clear that transmastoid decompression of the facial nerve alone is not appropriate, yet there are limited data supporting surgical decompression of the meatal segment of the facial nerve in patients with complete paralysis, with electrodiagnostic testing demonstrating severe denervation within 2 weeks of onset of paralysis. While the panel could make no recommendation regarding surgical decompression for Bell s palsy, based on the limited data supporting its effectiveness, the cost and risks of the intervention, and the logistical complexities of identifying proper surgical candidates and arranging for surgery in the narrow window during which it may be effective, the dramatic psychological consequences of facial paralysis to some patients may outweigh these concerns. Facial nerve decompression is not recommended in children, as most recover with nonsurgical management.28 Q3. Are their benefits associated with use of acupuncture in treating patients with Bell s palsy? There are several suggested theories regarding the physiologic mechanism of acupuncture, including increasing the excitability of the nerve and promoting regeneration of the nerve fibers and formation of collateral branches, enhancing muscle contraction and blood circulation to the nerves.29 However, there is little confirmatory evidence to support these hypotheses. Suggested acupoints are often chosen along Yang meridians, thought by practitioners to correspond to the facial nerve trunk and the facial musculature.30,31 In 1 systematic review, combinations of manual or electro-acupuncture with moxibustion (a traditional Chinese method involving burning herbal preparations containing mugwort) are recommended with a total course of 20 to 40 daily treatments, although frequency and duration of treatment are often individualized.31

A systematic review of acupuncture treatment of Bell s palsy by Chen et al29 included 6 RCTs with a total of 537 participants. Five RCTs used acupuncture, while 1 RCT used acupuncture combined with medication. Four RCTs compared acupuncture with medication, while 2 compared acupuncture with manipulation and physical therapy, respectively. Collectively, the RCTs suggested that there was a benefit effect of improved facial nerve recovery following acupuncture in treating Bell s palsy. However, the AAO-HNSF CPG panel noted methodological flaws, including a paucity of information regarding randomization, blinding, and completeness of outcome data, as well as a high risk of bias. In addition, outcome assessment varied between trials and prevented the data from being combined in a meta-analysis. Therefore, these trials do not permit reliable conclusions. A more recent systematic review of 8 RCTs conducted by Kim et al32 identified several important factors, including the stage or severity of the paralysis and when acupuncture treatment began, that were not considered in the previously conducted Chen et al29 review. Ameta-analysis of 4 trials showed a 7% higher recovery rate on various scales of facial nerve function of acupuncture alone compared with medical therapy alone.32 A meta-analysis of 6 trials also showed an 11% higher recovery rate on various scales of facial function with acupuncture plus medical therapy compared with medical therapy alone.32 However, the AAO-HNSF CPG panel concurs with Chen et al, noting that due to poor randomization, insufficient blinding methods, and high risk of bias, the number and quality of trials are inadequate to draw firm conclusions despite the efforts of Chen et al to combine studies for a meta-analysis. Moreover, the AAO-HNSF CPG panel notes that in accordance with the work of Vickers et al,33 most of the RCTs may reflect a selective publishing bias that clouds the generalizability of the results.34 Acupuncture practiced by well-educated, trained, and experienced practitioners appears relatively safe and of minimal risk.35 While acupuncture is popular and most widely practiced in China, most reports on the safety of acupuncture have been published elsewhere.35 Prospective studies of European origin estimate the incidence of mild acupuncture-related adverse events at 6.7% to 15%,36-40 while 2 observational studies estimate the incidence of serious adverse events to be between 0.024% and 2.2%.36,37 One systematic review of Chinese acupuncture literature cited a total of 479 cases of adverse events reported in the 115 articles included in the review, but the first authors of the included studies were members of medical departments, court jurisdictions, and police departments, and a minority of the study authors were the acupuncturists who performed the procedure that led to the adverse event.35 Whether the variation in reporting of adverse events is a reflection of the relative safety of acupuncture, the underreporting of adverse events, or the limited use of acupuncture remains unclear. Although age has been associated with a poorer response to acupuncture by some, it does not appear to be an independent risk factor for adverse outcomes.41 Unsupervised self-treatment is strongly discouraged, as improper technique is often the source of adverse outcomes.42 Persistent pleas for increasing safety standards and standardization of clinical acupuncture practices over the past decade in Europe and China (where acupuncture is more widely practiced) suggest acupuncture care delivery can be of variable quality,39,41,43,44 despite the very low reported incidence of serious adverse events: just 0.024% in 1 prospective observational study.36 In summary, while RCTs are available supporting the use of acupuncture, the AAO-HNSF CPG panel downgraded the value of these trials due to the poor quality of the studies. As a result, the AAO-HNSF CPG panel was unable to determine the ratio of benefit to harm and therefore could make no recommendation regarding the use of acupuncture. There is an opportunity to share with the patient the uncertainty about this treatment. There is a need for future, more rigorous RCTs that may overcome the limitations of the current evidence.

References

1. Pitaro J, Waissbluth S, Daniel SJ. Do children with Bell s palsy benefit from steroid treatment? A systematic review. Int J Pediatr Otorhinolaryngol. 2012;76:921-926.
2. Holland J. Bell s palsy. Clin Evid (Online). 2008;2008:1204.
3. Atzema C, Goldman RD. Should we use steroids to treat children with Bell s palsy?Can Fam Physician. 2006;52:313-314.
4. Pitaro K, Waissbluth S, Daniel SJ. Steroids in pediatric Bell palsy: a systematic review. Otolaryngol Head Neck Surg. 2011;145:246.
5. Salman MS, MacGregor DL. Should children with Bell s palsy be treated with corticosteroids? A systematic review. J Child Neurol. 2001;16:565-568.
6. Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell s palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:830-836.
7. McAllister K, Walker D, Donnan PT, Swan I. Surgical interventions for the early management of Bell s palsy. Cochrane Database Syst Rev. 2011;(2):CD007468.
8. Peitersen E. Natural history of Bell s palsy. Acta Otolaryngol Suppl. 1992;492:122-124.
9. Sullivan FM, Swan IR, Donnan PT, et al. Early treatment with prednisolone or acyclovir in Bell s palsy. N Engl J Med. 2007; 357:1598-1607. 10. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell s palsy. Laryngoscope. 1999;109:1177-1188. 11. Fisch U, Esslen E. Total intratemporal exposure of the facial nerve: pathologic findings in Bell s palsy. Arch Otolaryngol. 1972;95:335-341. 12. Gantz BJ, Gmur A, Fisch U. Intraoperative evoked electromyography in Bell s palsy. Am J Otolaryngol. 1982;3:273-278. 13. Yamamoto E, Fisch U. Experimentally induced facial nerve compression in cats. Acta Otolaryngol. 1975;79:390-395. 14. Ge XX, Spector GJ. Labyrinthine segment and geniculate ganglion of facial nerve in fetal and adult human temporal bones. Ann Otol Rhinol Laryngol Suppl. 1981;90:1-12. 15. Mechelse K, Goor G, Huizing EH, et al. Bell s palsy: prognostic criteria and evaluation of surgical decompression. Lancet. 1971;2:57-59. 16. Adour KK, Swanson PJ Jr.Facial paralysis in 403 consecutive patients: emphasis on treatment response in patients with Bell s palsy. Trans Am Acad Ophthalmol Otolaryngol. 1971; 75:1284-1301. 17. May M, Klein SR, Taylor FH. Indications for surgery for Bell s palsy. Am J Otol. 1984;5:503-512. 18. Aoyagi M, Koike Y, Ichige A. Results of facial nerve decompression. Acta Otolaryngol Suppl. 1988;446:101-105. 19. Yanagihara N, Hato N, Murakami S, Honda N. Transmastoid decompression as a treatment of Bell palsy. Otolaryngol Head Neck Surg. 2001;124:282-286. 20. Kim IS, Shin SH, Kim J, Lee WS, Lee HK. Correlation between MRI and operative findings in Bell s palsy and Ramsay Hunt syndrome. Yonsei Med J. 2007;48:963-968. 21. Fisch U. Surgery for Bell s palsy. Arch Otolaryngol. 1981; 107:1-11. 22. Bodenez C, Bernat I, Willer JC, Barre P, Lamas G, Tankere F. Facial nerve decompression for idiopathic Bell s palsy: report of 13 cases and literature review. J Laryngol Otol. 2010;124:272-278. 23. House WF, Shelton C. Middle fossa approach for acoustic tumor removal. Otolaryngol Clin North Am. 1992;25:347-359. 24. Brackmann DE, House JR III, Hitselberger WE. Technical modifications to the middle fossa craniotomy approach in removal of acoustic neuromas. Am J Otol. 1994;15:614-619. 25. Glasscock ME, McKennan KX, Levine SC. Acoustic neuroma surgery: the results of hearing conservation surgery. Laryngoscope. 1987;97:785-789. 26. Shelton C, Brackmann DE, House WF, Hitselberger WE. Middle fossa acoustic tumor surgery: results in 106 cases.Laryngoscope. 1989;99:405-408. 27. Smouha E, Toh E, Schaitkin BM. Surgical treatment of Bell s palsy: current attitudes. Laryngoscope. 2011;121:1965-1970. 28. Barr JS, Katz KA, Hazen A. Surgical management of facial nerve paralysis in the pediatric population. J Pediatr Surg. 2011;46:2168-2176. 29. Chen N, Zhou M, He L, Zhou D, Li N. Acupuncture for Bell s palsy. Cochrane Database Syst Rev. 2010;(8): CD002914. 30. Cheng KJ. Neuroanatomical basis of acupuncture treatment for some common illnesses. Acupunct Med. 2009;27:61-64. 31. Zheng H, Li Y, Chen M. Evidence based acupuncture practice recommendations for peripheral facial paralysis. Am J Chin Med. 2009;37:35-43. 32. Kim JI, Lee MS, Choi TY, Lee H, Kwon HJ. Acupuncture for Bell s palsy: a systematic review and meta-analysis. Chin J Integr Med. 2012;18:48-55. 33. Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Controlled Clin Trials. 1998;19:159-166. 34. Cumberworth A, Mabvuure NT, Norris JM, Watts S. Is acupuncture beneficial in the treatment of Bell s palsy? Best evidence topic (BET). Int J Surg. 2012;10:310-312. 35. Zhang J, Shang H, Gao X, Ernst E. Acupuncture-related adverse events: a systematic review of the Chinese literature. Bull World Health Organ. 2010;88:915C-921C. 36. Endres HG, Molsberger A, Lungenhausen M, Trampisch HJ. An internal standard for verifying the accuracy of serious adverse event reporting: the example of an acupuncture study of 190,924 patients. Eur J Med Res. 2004;9:545-551. 37. Witt CM, Pach D, Brinkhaus B, et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009;16:91-97. 38. Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years 1981-1994. J Altern Complement Med. 1996;2:291-297. 39. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ. 2001;323:485-486. 40. Macpherson H, Scullion A, Thomas KJ, Walters S. Patient reports of adverse events associated with acupuncture treatment: a prospective national survey. Qual Saf Health Care. 2004;13:349-355. 41. Park SU, Ko CN, Bae HS, et al. Short-term reactions to acupuncture treatment and adverse events following acupuncture: a cross-sectional survey of patient reports in Korea. J Altern Complement Med. 2009;15:1275-1283. 42. Yamashita H, Tsukayama H, White AR, Tanno Y, Sugishita C, Ernst E. Systematic review of adverse events following acupuncture: the Japanese literature. Complement Ther Med. 2001;9:98-104. 43. He W, Zhao X, Li Y, Xi Q, Guo Y. Adverse events following acupuncture: a systematic review of the Chinese literature for the years 1956-2010. J Altern Complement Med. 2012;18:892-901. 44. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004;22:122-133. 45. Brandenburg NA, Annegers JF. Incidence and risk factors for Bell s palsy in Laredo, Texas: 1974-1982. Neuroepidemiology.1993;12:313-325. 46. Katusic SK, Beard CM, Wiederholt WC, Bergstralh EJ, Kurland LT. Incidence, clinical features, and prognosis in Bell s palsy, Rochester, Minnesota, 1968-1982. Ann Neurol. 1986;20:622-627. 47. Monini S, Lazzarino AI, Iacolucci C, Buffoni A, Barbara M. Epidemiology of Bell s palsy in an Italian Health District: incidence and case-control study. Acta Otorhinolaryngol Ital. 2010;30:198. 48. Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell s palsy in the UK. Eur J Neurol. 2002;9:63-67. 49. Tsai HS, Chang LY, Lu CY, et al. Epidemiology and treatment of Bell s palsy in children in northern Taiwan. J Microbiol Immunol Infect. 2009;42:351-356. 50. Lunan R, Nagarajan L. Bell s palsy: a guideline proposal following a review of practice. J Paediatr Child Health. 2008;44: 219-220. 51. Rowhani-Rahbar A, Baxter R, Rasgon B, et al. Epidemiologic and clinical features of Bell s palsy among children in Northern California. Neuroepidemiology. 2012;38:252-258. 52. Peitersen E. Bell s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;(549):4-30. 53. Katz A, Sergienko R, Dior U, Wiznitzer A, Kaplan DM, Sheiner E. Bell s palsy during pregnancy: is it associated with adverse perinatal outcome? Laryngoscope. 2011;121:1395-1398. 54. Savadi-Oskouei D, Abedi A, Sadeghi-Bazargani H. Independent role of hypertension in Bell s palsy: a case-control study. Eur Neurol. 2008;60:253-257. 55. Byrne PJ. Importance of facial expression in facial nerve rehabilitation. Curr Opin Otolaryngol Head Neck Surg. 2004;12: 332-335. 56. Valente SM. Visual disfigurement and depression. Plast Surg Nurs. 2004;24:140-148. 57. Ishii L, Godoy A, Encarnacion CO, Byrne PJ, Boahene KD, Ishii M. Not just another face in the crowd: society s perceptions of facial paralysis. Laryngoscope. 2012;122:533-538.

WHY THIS TOPIC IS IMPORTANT: Bell s palsy is a relatively uncommon condition, but one that affects people across the age and sex spectrum, with incidence ranging from 11.5 to 53.3 per 100,000 person years in different populations.45-49 Notably, Bell s palsy is seen in the pediatricpopulation, with 1 study citing an incidence of approximately 6.1 in 100,000 in children 1 to 15 years of age.50 In 1 integrated health system, the incidence of Bell s palsy in children 18 years or younger was 18.8 per 100,000 person years in a 5-year study.51 In that study, the incidence rate increased by age and was higher in females than in males across all age strata. Although Bell s palsy is seen in patients across a large age spectrum, the incidence was noted to be highest in the 15- to 45-year-old age group.52 There are several known risk factors for Bell s palsy, including pregnancy. In a study of pregnant women, of 242,000 deliveries, 0.17% of expectant mothers were diagnosed with Bell s palsy.53 Obesity, chronic hypertension, and severe preeclampsia also increase the risk. Diabetes is also a risk factor, and hypertension may be independently associated with an increased risk of Bell s palsy.54 Risk factors for Bell s palsy include the following:

Pregnancy

Severe preeclampsia

Obesity

Hypertension and chronic hypertension

Diabetes

Upper respiratory ailments The psychological burden of facial paralysis can be tremendous. Facial expression is fundamental to one s sense of wellbeing and ability to integrate into a social network.55 With diminished facial movement and marked facial asymmetry, patients with facial paralysis can have impaired interpersonal relationships and experience profound social distress, depression, and social alienation.56 Recent data show that patients with facial paralysis are perceived by casual observers as emoting negatively compared with individuals without paralyzed faces and are considered significantly less attractive.57 There are links between diminished attractiveness and depression, and these data may suggest that patients with paralyzed faces are at risk for depression, which can lead to decreased productivity and increased health care expenses. Costs associated with Bell s palsy include those attributed to visits to the emergency room or urgent care, primary care, and laboratory and imaging studies. The evaluations described are myriad and may include audiometric, vestibular, electrical, and serologic tests, as well as CT imaging or MRI studies. A

gold standard

treatment has yet to be defined, and as such, medical and surgical intervention is variable. No explicit cost estimates for the diagnosis and management of Bell s palsy are available, but with 35,000 to 100,000 cases annually in the United States, based on aforementioned estimates of incidence, the cost of addressing Bell s palsy is undoubtedly significant.

HOW WILL AN ANSWER TO YOUR RESEARCH QUESTION BE USED OR HELP INFORM DECISIONS FOR YOU OR YOUR GROUP? The AAO-HNSF published a clinical practice guideline (CPG) on Bell s palsy in 2013. This CPG will need to be updated in 2018, therefore a systematic review would inform the update.

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

professional society

If you are you making a suggestion on behalf of an organization, please state the name of the organization

American Academy of Otolaryngology Head and Neck Surgery Foundation

Please tell us how you heard about the Effective Health Care Program