The Laryngoscope V C 2014 The American Laryngological, Rhinological and Otological Society, Inc. Prognostic Factors of Bell’s Palsy: Multivariate Analysis of Electrophysiological Findings Patrizia Mancini, MD, PhD; Daniele De Seta, MD; Luca Prosperini, MD, PhD; Maria Nicastri, MHS; Maria Gabriele, MD; Marco Ceccanti, MD; Giulio Sementilli, MD; Maria Terella, MD; Gian Antonio Bertoli, MD; Roberto Filipo, MD; Maurizio Inghilleri, MD Objectives/Hypothesis: The study was designed to verify if one or more electrophysiological parameters could predict a risk of nonrecovery of normal facial function and the development of synkinesis in Bell’s palsy (BP) subjects. Study Design: Prospective case series. Methods: A total of 120 subjects ranging from 18 to 70 years with unilateral BP (International Classification of Disease- 11), Grade III to VI House-Brackmann (HB) degree, were assessed and treated with standardized oral steroids and antiviral drugs within 48 hours from onset. Of these, 92 underwent electroneurography (ENoG), electromyography (EMG), and blink reflex (BR) testing at 7 to 10 and 20 days after palsy onset. Multivariate analysis and receiver operating characteristic curves were carried out to verify which combination of electrophysiological parameters may be predictive of no recovery and/or development of synkinesis. Results: BR and ENoG were the best predictors of no facial function recovery, showing significant correlation coefficient with severity of facial palsy in both assessments. EMG findings did not add any prognostic significance. Worsening of facial palsy can be observed in subjects despite steroid therapy. The risk of developing synkinesis might be evaluated soon after BP on the grounds of ENoG degeneration, orbicularis oculi denervation, a younger age, and severe (V–VI) HB grade. Conclusions: BR and ENoG, considered together with clinical findings, could offer a good indication in the first phases of BP for the possibility to develop palsy residua. This combination of tests is well accepted by the subjects, and is therefore suitable for multiple assessments in the early postpalsy period.Key Words: Bell’s palsy, facial palsy, ENoG, blink reflex, Prognosis. Key Words: Bell’s Palsy, facial palsy, ENoG, blink reflex, prognostic factors. Level of Evidence: 4. Laryngoscope, 124:2598–2605, 2014 INTRODUCTION Bell’s palsy (BP) is an idiopathic peripheral facial palsy (FP) with weakness of facial muscles with acute onset and no readily identifiable cause, due to unilateral dysfunction of the seventh cranial nerve (International Classification of Disease-10). It is the most frequent form of peripheral palsy of the facial nerve (FN), representing about 50% to 60% of all etiologies, with a variable annual incidence of 8 to 52.8 new cases/100.000 subjects. 1–3 Predictability of facial nerve paralysis outcomes are of essential importance for patient counseling and are a guide for clinical management. The higher percentage and shorter time of recovery is achieved when corticoste- roid therapy, 2–4 surgical decompression of the facial nerve, 5 and rehabilitation 6 are administered within the most favorable time frame. In 15% to 31% of cases, dif- ferent grades of sequelae remain, 2,7,8 among which facial synkinesis is the most common and serious problem. Several electrophysiological tests have been used to determine FP prognosis: electroneurography (ENoG), blink reflex test (BR), and needle electromyography (EMG) are the most frequently studied. Data on the prospective pre- dictive value of such tests are conflicting, mainly due to selection biases: etiology and degree of palsy 8–12 ; tests involved and ENoG cutoff value 8,10,11,13,14 ; initial timing for evaluation being between 5 to 10 days postonset 10,14,15 or otherwise 3,8,11–12,16 ; prognostic follow-up time set at 6 to 12 months, 8,10–12,17,18 or shorter. 12,15 Clinical predictors have been implemented to improve prognosis, 19,20 but these studies also are affected by biases linked to small study samples, 19 patient selection, and follow-up. 19,20 The present prospective study was designed to ver- ify in BP subjects whether one or a specific pattern of clinical and electrophysiological parameters could be considered as predictive of the degree of risk of nonre- covery of normal/near normal facial muscle function (I– II HB grade), and which parameter may be useful for the early identification of those subjects who could possi- bly develop synkinesis. From the Department of Sense Organs (P .M., D.D.S., M.N., G.S., M.T., G.A.B., R.F .), and the Department of Neurology and Psychiatry (L.P ., M.G., M.C., M.I.), University Sapienza, Rome, Italy. Editor’s Note: This Manuscript was accepted for publication May 7, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Patrizia Mancini, Department of Sense Organs, Universit a Sapienza–Roma, Policlinico Umberto I, Viale dell’Universit a 31, 00161 Roma, Italia. E-mail: p.mancini@uniroma1.it DOI: 10.1002/lary.24764 Laryngoscope 124: November 2014 Mancini et al.: Prognostic Factors of Bell’s Palsy 2598