Overimaging in Bell’s Palsy Undermines Clinical Guidelines and Escalates Systemic Waste

A new nationwide analysis of Bell’s palsy management patterns reveals a costly disconnect between clinical guidelines and frontline practice. The study, led by researchers at Mount Sinai Health System and published in The Laryngoscope, finds that nearly one in four patients with Bell’s palsy receives advanced imaging, despite clear recommendations discouraging routine use. These findings are not just a rebuke of outdated clinical habits; they are a warning sign for the systemic inefficiencies that persist in diagnostic care.

Drawing from two major commercial and Medicare claims databases, researchers reviewed the cases of nearly 36,000 adults diagnosed with Bell’s palsy. Despite the condition’s typical presentation being straightforward and self-limiting, 25% of these patients underwent CT or MRI scans within 30 days of diagnosis. This volume of imaging stands in sharp contrast to guidelines from the American Academy of Otolaryngology–Head and Neck Surgery, which recommend imaging only in the presence of atypical or progressive neurological symptoms.

While some imaging may be warranted in more severe or ambiguous cases, the magnitude of use here signals overreliance on technology as a diagnostic crutch, particularly when early corticosteroid treatment, not imaging, is the proven determinant of clinical recovery.

The Cost of Diagnostic Drift

Clinical drift, where actual practice subtly diverges from evidence-based standards, poses a silent but severe burden across the U.S. health system. In this case, the overuse of imaging for Bell’s palsy represents not only unnecessary exposure to radiation and contrast agents, but also a significant and avoidable expenditure. According to a 2024 study in Health Affairs, diagnostic imaging remains one of the most overutilized services in ambulatory care, contributing to an estimated $12 billion in excess annual spending.

The Mount Sinai analysis reinforces that a considerable portion of these costs stem from well-intentioned, yet misaligned, decisions. Providers may be motivated by a desire to rule out stroke or tumors in patients presenting with sudden facial paralysis, particularly when symptoms overlap with cerebrovascular conditions. But that instinct, however understandable, fails to align with the actual risk profile of typical Bell’s palsy cases, where recovery is likely and early pharmacological intervention is most effective.

Why Early Treatment, Not Early Scans, Matters

Clinical guidelines consistently endorse high-dose corticosteroids initiated within 72 hours of symptom onset as the cornerstone of Bell’s palsy treatment. Imaging does not improve outcomes in otherwise healthy patients who show classic signs of the condition. Yet, the study found a correlation between imaging use and increased likelihood of receiving both steroids and antivirals, suggesting a hesitancy to initiate treatment without confirmatory scans.

This hesitancy may introduce delays, contradicting the very timing that makes steroid treatment effective. As noted by the Centers for Disease Control and Prevention (CDC), delayed therapy reduces the likelihood of full nerve recovery, potentially leading to long-term functional or aesthetic deficits for the patient.

Training Gaps or Systemic Inertia?

While the study authors call for broader dissemination of clinical guidelines, the problem may run deeper than awareness. Multiple specialties—including emergency medicine, neurology, and primary care—may encounter Bell’s palsy in clinical settings. Without a shared protocol or centralized guideline enforcement, variability in practice becomes the norm.

The National Academy of Medicine has previously emphasized the importance of clinical decision support tools and real-time care pathways to reduce unwarranted variation. Yet, few EHR systems today offer built-in support for Bell’s palsy-specific treatment guidance. Until such tools are embedded across care environments, alignment with best practices may remain aspirational.

A Broader Equity Question Emerges

Notably, the current study focuses exclusively on patients with private insurance or Medicare coverage, leveraging data from the MarketScan Commercial and Supplemental databases. This raises questions about how imaging trends might differ among Medicaid populations or uninsured patients, groups often subject to different care environments, reimbursement limitations, and systemic biases.

Prior research from KFF and Health Affairs has shown that racial and socioeconomic disparities persist in both overuse and underuse of diagnostic testing. Further investigation is needed to determine whether marginalized populations experience the same pattern of overimaging, or if they are instead being underserved when guideline-based interventions are needed.

Toward Smarter, Standardized Care

The Mount Sinai-led research is a clarion call for recalibrating how common, low-risk conditions are managed across care settings. Rather than defaulting to expensive, low-yield diagnostics, clinicians need institutional support to trust clinical judgment backed by validated evidence.

Several strategies can help reinforce guideline-concordant care:

• Integrate real-time alerts and pathways into EHRs for conditions like Bell’s palsy, prompting early corticosteroid use and flagging unnecessary imaging orders.
• Standardize treatment protocols across emergency departments, urgent care centers, and primary care clinics where initial presentation is likely to occur.
• Launch quality metrics tied to imaging appropriateness in non-traumatic cranial nerve disorders, similar to CMS’s imaging efficiency metrics in stroke and low back pain.
• Expand academic detailing and continuing medical education on low-value care reduction, with Bell’s palsy used as a teaching case.

Without systemic alignment, well-established guidelines will continue to be outpaced by reflexive ordering practices and the false reassurance of “just in case” imaging.

Reframing the Default

Imaging is not inherently wasteful. When used judiciously, it can clarify ambiguous diagnoses, rule out life-threatening pathology, and direct appropriate specialist referral. But in the case of Bell’s palsy, imaging often provides little actionable information and risks displacing the interventions that matter most.

This study doesn’t just catalog a practice gap. It also illustrates a broader problem: the persistent overengineering of diagnostic care at the expense of timely, evidence-based treatment. Unless institutions commit to supporting clinical discipline over diagnostic excess, this pattern will persist, not just in Bell’s palsy, but across a wide swath of common conditions.