Recurrent and Bilateral Facial Palsy in Bell’s Palsy and Ramsay-Hunt Syndrome: Risk Factors and Clinical Outcomes

BACKGROUND: Most patients with Bell’s Palsy or Ramsay Hunt Syndrome experience nonrecurrent unilateral facial palsy while only a subset of patients experience recurrent or bilateral events for which risk factors remain poorly defined. This study aimed to identify risk factors and severity associated with recurrent and bilateral facial palsy. METHODS: A retrospective study included Bell’s palsy and Ramsay Hunt syndrome patients with recurrent and bilateral facial palsy from 2009 to 2025. The primary outcome was identification of risk factors for recurrence and bilaterality comparing each group with a nonrecurrent unilateral group. Secondary outcome of facial palsy severity was performed using Facial Nerve Clinician-Graded Scale (eFACE). Patients with differing recurrence etiologies were excluded. RESULTS: Of 1,108 patients, 440 were included. Thirty (6.8%) had recurrence and 32 (7.3%) bilaterality. Age under 40 at onset was associated with recurrence (p = 0.017) and autoimmune disease with bilaterality (p = 0.030). Severity did not differ between recurrent (p = 0.583) nor bilateral (p = 0.205) groups when compared with the nonrecurrent unilateral group. Patients with Bell’s palsy and Ramsay Hunt syndrome had similar rates recurrence (p = 0.922), bilaterality (p = 0.403), and severity (p = 0.169). Events occurred around one decade apart. CONCLUSIONS: Younger age was associated with recurrence, and autoimmune disease with bilaterality. Severity did not differ in recurrent or bilateral cases, when compared with a nonrecurrent unilateral cohort, nor when comparing Bell’s palsy with Ramsay Hunt syndrome. Recurrence and bilaterality rates were similar between etiologies occurring about one decade apart.