Bell’s Palsy


Bell's palsy is an idiopathic lower motor neurone palsy that affects the muscles of the face due to a problem with the facial nerve. The weakness usually affects one side of the face but in rare cases both sides are affected. Many people who have a Bell's palsy initially believe they have had a stroke. However, unlike stroke a full recovery from Bell's palsy occurs in most cases.  Its onset is usually over a few hours or overnight, and its incidence is 25-35 per 100,000




  • Maximum facial weakness develops within 2 days
  • Earache, pain behind the ear, aural fullness, or facial pain may precede the palsy
  • Severe pain might indicate Ramsay Hunt syndrome. This is caused by herpes zoster and is associated with a painful rash and herpetic vesicles
  • Only the facial nerve is affected


Confirm that the paralysis is caused by a unilateral, lower motor neuron lesion:

  • In a lower motor neurone lesion, the muscles controlling facial expression are affected on one side of the face only. This may result in drooping of the brow and corner of the mouth, weakness of the frontalis (forehead muscle), or inability to close the eye
  • In an upper motor neuron lesion, wrinkling of the brow, eye closure, and blinking are not affected


Loss of taste of the anterior two-thirds of the tongue (on the same side as the facial weakness) may occur


Exclude serious underlying pathology:

  • Evidence of asymmetry of the oropharynx and ipsilateral tonsil might indicate a parotid tumour
  • Hearing impairment, discharge, bleeding, dizziness, vertigo, disorder of balance, pain, headaches, or tinnitus are symptomatic of cholesteatoma
  • Evidence of polyposis or granulations are suggestive of malignant otitis externa
  • A rash on the limbs or trunk following a tick bite might indicate Lyme disease


Patient advice

  1. Reassure the person that the prognosis is good:  most people with Bell's palsy make a full recovery within 9 months
  2. Advise the person that:
    1. It is important to keep the affected eye lubricated. Lubricating eye drops should be used during the day and eye ointment used at night
    2. If the cornea is exposed after attempting to close the eyes they should seek prompt medical advice
    3. If they are unable to close the eye at bedtime they should tape it closed using microporous tape
    4. If there is concern about soreness of the eye or decrease in visual acuity the patient should be referred to ophthalmology


Treatment and Management

For people presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone

  • There is no consensus regarding the optimum dosing regimen, but options include:
    • Giving 25 mg twice daily for 10 days, or
    • Giving 60 mg daily for five days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred
  • Review the patient at 1 week after starting prednisolone (to ensure they are no worse) and then at 6 weeks (to ensure there is improvement)


NOTE Antiviral treatments are not recommended, either alone or in combination with prednisolone


When to refer

Refer urgently to neurology or to ENT if there is:

  • Any doubt regarding the diagnosis
  • Recurrent Bell's palsy
  • Bilateral Bell's palsy


If the cornea remains exposed after attempting to close the eyelid, refer urgently to ophthalmology

If the paralysis shows no sign of improvement after 1 month, or there is suspicion of a serious underlying diagnosis (e.g. cholesteatoma, parotid tumour, malignant otitis externa), refer urgently to ENT

If there is residual paralysis after 6–9 months, consider referral to a plastic surgeon with a special interest in facial reconstructive surgery


NOTE Children under 16, patients who are pregnant or who have diabetes should always be referred via the on call ENT doctor


Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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