Upper–Lower Discordance and Recovery Patterns in Bell’s Palsy: A Region-Specific Analysis Using House–Brackmann Grading

INTRODUCTION: Bell's palsy is the most common acute unilateral facial paralysis. House-Brackmann (HB) grading may mask region-specific involvement; therefore, we evaluated upper and lower facial regions separately and examined factors associated with recovery. METHODS: Adults presenting within 3 days of symptom onset (January 2024-January 2025) were followed at day 15, day 30, and month 6. Standardized photographs were graded using upper and lower HB grades by three blinded otolaryngologists (median score used). Treatment patterns (no treatment, steroid only, steroid+physiotherapy) and comorbidities (diabetes mellitus [DM], hypertension [HT]) were recorded. RESULTS: The final cohort included 213 patients. Upper-lower HB grades were discordant at presentation in 89 patients (41.8%). HB improved significantly over time in both regions(p<0.001). Lower-face HB grades were consistently higher at early time points, indicating greater initial severity in the lower facial region. Steroid exposure was associated with different early recovery trajectories from day 1 to day 30 (upper: p=0.001; lower: p=0.026). DM and HT were linked to less favorable recovery patterns, without a significant synergistic effect. CONCLUSION: Separate upper and lower HB grading reveals clinically meaningful heterogeneity in Bell's palsy. Region-specific assessment may improve prognostic stratification at presentation. Corticosteroid therapy was associated with accelerated early recovery, whereas diabetes mellitus and hypertension adversely influence outcomes. Future studies incorporating region-specific assessment are needed to clarify its role in prognostic stratification and its potential contribution to individualized patient management.