Bell’s Palsy

Comes on over a period of 12 – 36 hours. Prodromes can happen – facial numbness, altered taste, or pain around the ear. Initially progressive, but progression should have halted by 3/52 and if it continues to progress after that time think possible SOL. Recovery takes place over about 3 – 6 months.

The facial nerve carries taste fibres from the anterior two-thirds of the tongue and fibres to the tear glands, and controls the staepedius muscle. Symptoms can therefore include:

  • Dry eye or excessive tearing
  • Altered taste sensation
  • Increased sensitivity to loud noise
  • Ear pain

Check for other neurological signs, the presence of which excludes Bell’s palsy. Also check for shingles in the external auditory meatus and the mouth – Ramsay Hunt syndrome. If detected, discuss with ENT whether to treat with antivirals +/- steroids. Check BP and blood glucose – hypertension & diabetes can cause facial palsy.

Remember that sparing of the forehead suggests upper motor neurone lesion rather than Bell’s.

Eye care:

  • Drops during the day
  • Regularly close eyelid manually during the day
  • Lacri-lube and eye pad at night
  • Wear glasses

Refer to ophthalmology if concerns about eye care.

No clear evidence as to optimum steroid dose – most common recommendation is for 60 – 80 mg Prednisolone od for 7/7. Unclear whether it’s better to stop or do gradual reduction after that. There is in fact borderline evidence for antivirals from meta-analysis – aciclovir 400 mg 5 x daily for ten days or valaciclovir 1 g tds for one week. However, if renal function is poor these should be avoided as can precipitate decline in renal function.

Review at 3/52 to check starting to recover and 6/12 to check recovered.

Refer if:

  • Atypical presentation/doubt over diagnosis
  • Progressive after 3/52
  • Not resolved at 6/12
  • Bilateral
  • Occurs in pregnancy.

Options if doesn’t fully recover:

  • Facial physio
  • Tarsorraphy to improve eye closure if needed (gold weight placed in eyelid)
  • Plastic surgery to improve appearance

(From BMJ learning module)


About Dr Sarah

I'm a GP with a husband and two young children.
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