Increasing Incidence of Facial Nerve Disorders in the United States from 2007 to 2022

Eric X Wei; Allen Green; Jon‐Paul Pepper; Sarah R Akkina

doi:10.1002/lary.31997

. 2025 Jan 10;135(6):2008–2013. doi: 10.1002/lary.31997

Increasing Incidence of Facial Nerve Disorders in the United States from 2007 to 2022

Eric X Wei ¹, Allen Green ¹, Jon‐Paul Pepper ¹, Sarah R Akkina ^2,^✉

PMCID: PMC12082024 PMID: 39791289

Abstract

Background

Incidence data on Facial Nerve Disorders (FND) and Bell's palsy are currently limited. Prior epidemiological studies have estimated the incidence rate of Bell's palsy to be between 11 and 53/100,000 individuals, although the most cited incidence data are from single regions or municipalities, many of which are outdated from several decades ago.

Methods

This was a retrospective cohort study of US adults from 2007 to 2022 using the Merative™ Marketscan® Research Databases. Trends in the incidence of FND were described overall and by specific sociodemographic groups, including age, sex, region, and insurance plan type. Chi‐squared and simple logistic regression analyses were performed.

Results

From 2007 to 2022, the total adult incidence of all FND was 30.5/100,000, and the total incidence of Bell's palsy alone was 24.5/100,000. Over the study period, there was a significant annual increase of 2.1 cases of FND/100,000 adults (95% Confidence Interval [CI] 1.8, 2.3; p < 0.001), and a significant total increase of 1.5 cases of Bell's palsy/100,000 adults (95% CI 1.2, 1.7; p < 0.001). The total incidence of FND was higher in males (33.1/100,000) than in females (28.4/100,000, p < 0.001), and greater in older age groups (p < 0.001). Additionally, the incidence of FND varied significantly by region (p < 0.001) and insurance plan type (p < 0.001).

Conclusions

This study provides up‐to‐date incidence rates for Bell's palsy and facial nerve disorders, based on national administrative claims data. Incidence rates of FND and Bell's palsy alone have been increasing in the United States from 2007 to 2022.

Level of Evidence

3 Laryngoscope, 135:2008–2013, 2025

Keywords: Bell's palsy, facial nerve disorders, facial palsy, facial paralysis, hemifacial spasm, incidence, United States

In this study of national administrative claims data from 2007 to 2022, the mean annual incidence of facial nerve disorders was 30.5 cases per 100,000 adults. The mean annual incidence of Bell's palsy alone was found to be 24.5/100,000, with increasing annual incidence rates during the study period. Sex, age, insurance plan type, and region were significantly related to rates of diagnoses of facial nerve disorders.

graphic file with name LARY-135-2008-g003.jpg

INTRODUCTION

Facial nerve disorders (FNDs) are a group of conditions with profound and widespread functional and psychosocial consequences. Patients with facial nerve disorders may have trouble with nasal breathing, issues with articulation and oral competence, impairments in corneal protection, and loss of expressional cues with nonverbal communication, among many other substantial life‐altering impairments.¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹ Additionally, facial nerve disorders are associated with significantly reduced quality of life and high rates of depression.¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰

With a rising number of facial nerve centers and experts across the United States, care for patients with facial nerve disorders is becoming increasingly more accessible. ²¹ However, data on incidence rates of facial nerve disorders are quite limited, with the most frequently referenced studies in the literature coming from single municipalities or regions, many of which were published decades ago.²²^,²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹ Accurate and up‐to‐date incidence rates on rare diseases are important to help appropriately evaluate healthcare needs on a population level as well as to drive the development of new therapeutics. As such, a better understanding of incidence rates of facial nerve disorders from large‐scale studies is needed from both clinical and research perspectives.

This study used administrative claims data from 2007 to 2022 to examine incidence rates of facial nerve disorders with an additional focus on Bell's palsy: the most common cause of facial palsy. Sociodemographic differences in diagnoses of facial nerve disorders were also evaluated. This study provides up‐to‐date incidence rates over a 16‐year period in a national cohort. Additionally, this work also provides novel insights into temporal trends in the diagnoses of facial nerve disorders.

METHODS

A retrospective analysis of administrative claims data from January 1, 2007, to December 31, 2022, was performed using the Merative™ Marketscan® Research Databases. The database contains de‐identified data from over 300 million unique individuals in the United States who are insured through employer‐sponsored or Medicare Advantage private health insurance. The dataset does not include claims from public insurance plans such as Medicaid or Medicare. The data are available publicly to researchers for a fee. This study was approved by the Institutional Review Board protocol for Stanford University Center for Population Health Science (IRB PHS 40974).

Individuals 18 years of age or greater diagnosed with facial nerve disorders were identified using the International Classification of Diseases, version 9 and 10 (ICD‐9/ICD‐10) codes listed in Table S1. Diagnoses accounting for ≤0.2% of the total cohort (i.e., Melkersson's syndrome, geniculate ganglionitis) were put in the other/unspecified disorders group. Central causes of facial weakness, including hemorrhagic or ischemic stroke and facial myokymia, were excluded in these analyses. These codes were used to select patients from outpatient, inpatient, emergency room, operating room, and/or ambulatory surgical center service encounters. To quantify yearly population counts for incidence rate calculations, we identified unique patients within the database who had at least one insurance claim related to outpatient or inpatient visits, emergency room visits, operating room services, and/or ambulatory surgical center services in a given calendar year. Patients' age, sex, region (North Central [IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI], Northeast [CT, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT], South [AL, AR, FL, GA, KY, LA, MS, NC, OK, SC, TN, TX, VA, WV], West [AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY], Unknown), and type of insurance plan (Preferred Provider Organization [PPO], Point‐of‐Service [POS] +/− capitation, Health Maintenance Organization [HMO], Consumer Directed Health Plan [CDHP], other) with or without Medicare Plus were obtained.

Statistical analyses were performed using Stata 16 (StataCorp). Incidence of facial nerve disorders was presented as means with standard deviations. Demographic, temporal, and clinical factors between the groups were compared using χ ² tests and simple logistic regression analysis, with statistical significance set at an alpha ≤0.05.

RESULTS

In this study, using the Merative™ Marketscan® Research Databases, we identified 119,793 adults who were diagnosed with facial nerve disorders from 2007 to 2022. The majority (80.4%) had a diagnosis of Bell's palsy (Figure 1). Total incidence of facial nerve disorders was 30.5/100,000. Incidence rates of facial nerve disorders were higher in males (33.1/100,000) relative to females (28.5/100,000, p < 0.001; Table I), and greatest in the oldest age group (18–34: 22.4/100,000; 35–44: 30.6/100,000; 45–54: 33.5/100,000; 55–64 33.3/100,000; 65+: 39.2; p < 0.001). The mean incidence of facial nerve disorders varied significantly by region, with rates lowest in the Northeast (25.2/100,000), followed by West (28.1/100,000), South (32.1/100,000), and North Central regions (34.5/100,000; p < 0.001). When examining patients with private insurance only, individuals with HMO insurance plans had the lowest mean incidence rates of facial nerve disorders compared with other insurance plans (HMO 28.6/100,000; POS +/− capitation 30.4/100,000; PPO 31.1/100,000; CDHP 32.3/100,000; p < 0.001).

Fig. 1 — Distribution of Facial Nerve Disorders (FND), 2007–2022, Merative™ Marketscan® Research Databases. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

TABLE I.

Incidence of Facial Nerve Disorders, Merative™ Marketscan® Research Databases 2007–2022.

	Facial Nerve Disorders
	Total Cases	Cases Per 100,000	p‐Value
Sex			p < 0.001
Male	56,549	33.1
Female	63,244	28.4
Age Group			p < 0.001
18–34	24,065	22.4
35–44	22,806	30.6
45–54	29,076	33.5
55–64	27,910	33.3
65+	15,936	39.2
Region^**			p < 0.001
North Central	30,869	34.4
Northeast	18,339	25.2
South	50,340	32.1
West	18,737	28.1
Unknown	1,508	20.0
Insurance Plan Type			p < 0.001
PPO	71,563	31.8
POS +/− capitation	9,944	30.6
HMO	15,102	31.2
CDHP	7,461	32.3
Other	15,723	34.1

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Bold p‐values indicate statistically significant result (p < 0.05).

CDHP = Consumer Directed Health Plan; HMO = Health Maintenance Organization; Other = Basic, Comprehensive, Exclusive Provider Organization, High‐Deductible Health Plan; POS = Point‐of‐Service; PPO = Preferred Provider Organization.

^**

Regions consist of: the following states North Central [IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI], Northeast [CT, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT], South [AL, AR, FL, GA, KY, LA, MS, NC, OK, SC, TN, TX, VA, WV], West [AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY].

The incidence of facial nerve disorders increased during the study period from 17.6/100,000 adults in 2007 to 47.4/100,000 in 2022 (Figure 2). In simple regression analyses, there was a significant annual increase of 2.1 cases of FND/100,000 adults (95% Confidence Interval [CI] 1.8, 2.3; p < 0.001). The total incidence of Bell's palsy over all study period years was found to be 24.5/100,000. Similarly, the incidence of Bell's palsy increased during the study period increased from 15.2/100,000 in 2007 to 35.3/100,000 in 2022. In simple regression analyses, there was a significant annual increase of 1.5 cases of Bell's palsy/100,000 adults (95% CI 1.2, 1.7; p < 0.001). Moreover, the incidence of non‐Bell's palsy related facial nerve disorders also increased during the study period from 2.4/100,000 adults in 2007 to 12.0/100,000 adults in 2022, resulting in a significant annual increase of 0.60 cases/100,000 adults (95% CI 0.52, 0.68; p < 0.001).

Fig. 2 — Incidence of Facial Nerve Disorders (FND) per 100,000 Adults, 2007–2022, Merative™ Marketscan® Research Databases: A) Bell's palsy and all FND; B) FND by sex; C) FND by age group; and D) FND by region. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

DISCUSSION

In this large‐scale study of administrative claims data across the United States from 2007 to 2022, we found that the total incidence of Bell's palsy was 24.5 per 100,000 person‐years while the total incidence rate of all facial nerve disorders was 30.5 per 100,000 person‐years. Prior epidemiological studies have estimated Bell's palsy incidence rates between 11 and 53/100,000.²²^,²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹ Of note, the vast majority of prior work reporting the incidence of Bell's palsy have been limited to single municipalities or regions,²²^,²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸ or were published over two decades ago. ²⁹ Our findings thus build off of prior work examining the incidence of Bell's palsy and other facial nerve disorders by presenting results from modern, large‐scale national claims data over a period of 16 years.

Interestingly, we found that the incidence rates of both Bell's palsy and all facial nerve disorders significantly increased during the study period at a rate of 1.5/100,000 individual‐years and 2.1 per 100,000 individual‐years, respectively. The reasons behind these temporal trends are unclear. Several recent studies have reported an association between COVID‐19 infection and facial palsy.³⁰^,³¹^,³²^,³³ One study found that individuals with COVID‐19 infection had a 6.8 relative risk of Bell's palsy compared with individuals vaccinated against COVID‐19. ³² However, although the COVID‐19 pandemic may be a possible driver of increasing incidence rates in the most recent years, our data suggest that increasing incidence rates of Bell's palsy and all facial nerve disorders began earlier, and has been gradually increasing over the study period, as shown in Figure 2. Although it is possible that the true incidence rate of Bell's palsy has been increasing, evidence for this claim is sparse. One epidemiological study in Korea reported that the incidence of Bell's palsy increased from 23.0 per 100,000 person‐years in 2008 to 30.8 per 100,000 person‐years in 2018. Another smaller study demonstrated an increasing incidence rate of Bell's palsy when comparing data in 2000–2010 with 1968–1982 in a single US county. ²⁸ Of note, we additionally observed an over fourfold increase in non‐Bell's palsy facial nerve disorders incidence during our study period. It is unclear what specific etiologies are driving these differences due to over 92% of these cases being diagnosed as unspecified or other facial nerve disorders. Unfortunately, there is a lack of more specific codes for many facial nerve disorders, such as rheumatoid neuritis, Parry–Romberg syndrome, and facial nerve lesions, among others. Many of these unspecified cases could also very well be undiagnosed Bell's palsy or facial nerve trauma that was undergoing clinical work‐up at the time of the encounter. Interestingly, facial nerve trauma only made up 1.5% of our study cohort. However, previous studies report that facial nerve trauma accounts for 6–27% of all facial nerve dysfunction cases.³⁴^,³⁵ Given the nature of our data, and lack of more granular details, it is difficult to deduce whether these patients have a history consistent with concern for traumatic injury.

The role of the Affordable Care Act (ACA) and changes in health insurance coverage should also be considered as a potential contributor to the increasing diagnoses rates of facial nerve disorders. Between the signing of the ACA in 2010 and 2015 when most of its major provisions were implemented, the uninsured rate in the United States declined by 43% from 16.0% to 9.1%. ³⁶ The implementation of the ACA, and specifically Medicaid expansion in 2014, has been shown across multiple fields of medicine to have to led to more timely diagnoses, increased access to appropriate surgical care, and improved outcomes.³⁷^,³⁸^,³⁹^,⁴⁰ For example, one study of patients with glottic cancer found that patients in Medicaid expansion states after its implementation were diagnosed at earlier stages and had increased rates of appropriate surgical therapy. ⁴¹ As such, it is possible that with a greater percentage of the population insured over time (i.e. improved healthcare access), there may be increasing diagnoses of relatively rare diseases such as facial nerve disorders. Another potential explanation is that the increase in incidence over the study period may reflect a greater awareness of facial nerve disorders and the available treatment options for these patients. With a proliferation of multidisciplinary facial nerve treatment teams across the United States in the past two decades, ²¹ there is greater recognition of potential treatments and the importance of timely evaluation and subspecialty referral, which may in turn be driving increasing diagnoses rates. ⁴² Future studies are needed to investigate the etiologies of these diagnostic trends; for now however, it is likely that multiple factors are contributing to these findings.

Additionally, we demonstrate significant differences in diagnoses rates of facial nerve disorders by age and sex. The association between greater age and increased incidence of facial nerve disorders, including Bell's palsy, has been documented previously, with several studies demonstrating the highest incidence rates in the oldest age groups.²⁶^,²⁷^,²⁹ With regard to sex, the majority of prior smaller studies examining Bell's palsy by sex have found no significant differences in incidence by sex, although these studies are limited by smaller sample sizes.²⁶^,²⁹^,⁴³ We found that the incidence of facial nerve disorders was significantly higher in males (33.1/100,000) relative to females (28.5/100,000) in our cohort. Recent studies examining sex differences in patients with facial nerve disorders have demonstrated lower quality of life scores among female patients,¹³^,¹⁶ as well as increased rates of surgical treatment in male patients.⁴⁴^,⁴⁵ Our study builds on this work by showing higher rates of diagnoses in males relative to females. Future work is needed to investigate whether the difference in incidence rates by sex reflects true biological variation or whether it is due to confounding factors such as healthcare utilization or medical comorbidities.

We also found significant differences in diagnoses rates of facial nerve disorders by region. Among the four US geographic regions, we found the lowest rates of diagnoses of facial nerve disorders in the Northeast. There are limited data comparing the incidence of facial nerve disorders by different geographic regions. One study of US military service personnel published two decades ago compared three US geographic regions—North, Southeast, and Southwest/South central—and found that relative to the Southwest/South central region, the incidence of Bell's palsy in the North region was significantly lower while controlling for demographic confounders. ⁴³ The same study found that arid climate was associated with a higher incidence compared with nonarid climates, with the authors theorizing that this association may be mediated by greater ultraviolet radiation, leading to reactivation of latent HSV‐1 infections. ⁴³ Although recent studies on facial nerve disorders have shown some regional differences in the rates of surgical treatment, ⁴⁵ our study extends these findings by characterizing regional differences in diagnoses rates as well.

The association between insurance plan type and incidence of facial nerve disorders is also novel and likely reflects differences in healthcare access and utilization. Prior research on HMOs has found that patients with certain conditions with HMO plans utilize significantly less ambulatory care than similar patients with fee‐for‐service plans.⁴⁶^,⁴⁷ Interestingly, we found that patients with HMO plan types had the lowest incidence rates of facial nerve disorders among all insurance plan types in the current database. It is possible that HMO plans may limit access to facial nerve centers that are out of network, where patients may be more likely to receive a diagnosis of a facial nerve disorder. Future work is needed to understand whether insurance plan type might affect the likelihood of surgical treatment and outcomes among patients with facial nerve disorders.

We note important limitations of this study. First, the study used claims data, which are susceptible to coding errors and codes that may be nonspecific. Second, although the study includes individuals of varying types of insurance plans, all individuals in the cohort are completely or partially privately insured, and as such these results may not extrapolate to patients with facial nerve disorders who are publicly insured or uninsured. Likewise, given that these data only capture medical insurance claims, individuals who receive their care from providers or practices that do not accept insurance would also be excluded from these incidence analyses. Third, the use of administrative claims data limits our ability to account and control for important risk factors and comorbidities such as facial palsy family history, obesity, pregnancy, or viral infections.⁴⁸^,⁴⁹ In addition, we did not have access to more pertinent sociodemographic data such as race, ethnicity, or income in our cohort. Despite these limitations, this study adds to the growing literature by providing up‐to‐date incidence rates from a large‐scale national dataset over a period of 16 years.

CONCLUSION

In summary, we demonstrate increasing diagnosis of facial nerve disorders including Bell's palsy in the United States from 2007 to 2022. Moreover, these analyses illustrate important associations between sociodemographic variables on diagnosis of facial nerve disorders on a national level. Future work is needed to investigate the underlying mechanisms driving these diagnostic trends, including factors that may be impacting increasing diagnoses rates of facial nerve disorders over time.

Supporting information

Data S1. Table S1. List of ICD‐9/10 codes.

LARY-135-2008-s001.docx^{(14.8KB, docx)}

ACKNOWLEDGMENTS

Data for this project were accessed using the Stanford Center for Population Health Sciences Data Core (Stanford Center for Population Health Sciences. (2023). MarketScan Databases (Version 3.0) [Data set]. Redivis (RRID:SCR_023111). https://doi.org/10.57761/kg3j-nh50). The PHS Data Core is supported by a National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award (UL1TR003142) and from Internal Stanford funding. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. (Stanford Center for Population Health Sciences. (2023)).

Editor's Note: This Manuscript was accepted for publication on December 27, 2024.

Eric X. Wei and Allen Green contributed equally to this work as first authors.

Jon‐Paul Pepper and Sarah R. Akkina contributed equally to this work as senior authors.

The authors have no funding, financial relationships, or conflicts of interest to disclose.

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39. Khansa I, Khansa L, Pearson GD. Surgeon reimbursements in maxillofacial trauma surgery: effect of the affordable care act in Ohio. Plast Reconstr Surg. 2016;137(2):613‐618. 10.1097/01.prs.0000475772.91525.26. [DOI] [PubMed] [Google Scholar]
40. Eguia E, Baker MS, Bechara C, Shames M, Kuo PC. The impact of the affordable care act Medicaid expansion on vascular surgery. Ann Vasc Surg. 2020;66:454‐461.e1. 10.1016/j.avsg.2020.01.006. [DOI] [PubMed] [Google Scholar]
41. Panuganti BA, Stuart E, Weissbrod P. Changes in treatment trends in the early glottic cancer population after the affordable care act. Head Neck. 2021;43(1):137‐144. 10.1002/hed.26463. [DOI] [PubMed] [Google Scholar]
42. Ziai K, Agarwal A, Daher GS, Saadi RA, Lighthall JG. Facial paralysis referral patterns to a multidisciplinary facial nerve clinic. Facial Plast Surg Aesthetic Med. 2023;25(5):440‐441. 10.1089/fpsam.2022.0372. [DOI] [PubMed] [Google Scholar]
43. Campbell KE. Effects of climate, latitude, and season on the incidence of Bell's palsy in the US armed forces, October 1997 to September 1999. Am J Epidemiol. 2002;156(1):32‐39. 10.1093/aje/kwf009. [DOI] [PubMed] [Google Scholar]
44. Crawford KL, Ball LL, Kalavacherla S, Greene JJ, Nguyen QT, Orosco RK. Race and sex demographics in the surgical management of facial nerve palsy. Laryngoscope Investig Otolaryngol. 2023;8(3):639‐644. 10.1002/lio2.1053. [DOI] [PMC free article] [PubMed] [Google Scholar]
45. Derakhshan A, Shaye D, McCarty JC, et al. Surgical Management of Facial Paralysis: demographic and socioeconomic associations. Facial Plast Surg Aesthetic Med. 2023;25(2):165‐171. 10.1089/fpsam.2021.0353. [DOI] [PubMed] [Google Scholar]
46. Yelin E, Trupin L, Earnest G, Katz P, Eisner M, Blanc P. The impact of managed care on health care utilization among adults with asthma. J Asthma. 2004;41(2):229‐242. 10.1081/JAS-120026081. [DOI] [PubMed] [Google Scholar]
47. Yelin E, Trupin L, Katz P, et al. Impact of health maintenance organizations and fee‐for‐service on health care utilization among people with systemic lupus erythematosus. Arthritis Care Res. 2007;57(3):508‐515. 10.1002/art.22625. [DOI] [PMC free article] [PubMed] [Google Scholar]
48. Evangelista V, Gooding MS, Pereira L. Bell's palsy in pregnancy. Obstet Gynecol Surv. 2019;74(11):674‐678. [DOI] [PubMed] [Google Scholar]
49. Tiemstra JD, Khatkhate N. Bell's palsy: diagnosis and management. Am Fam Physician. 2007;76:7. [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Data S1. Table S1. List of ICD‐9/10 codes.

LARY-135-2008-s001.docx^{(14.8KB, docx)}

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PERMALINK

Increasing Incidence of Facial Nerve Disorders in the United States from 2007 to 2022

Eric X Wei, MD

Allen Green, BS

Jon‐Paul Pepper, MD

Sarah R Akkina, MD