Bells Palsy

Symptoms

Bell’s Palsy is a sudden onset, normally within 72 hours, idiopathic unilateral lower motor neurone facial weakness. The weakness involves the whole face whereas with an upper motor neurone facial palsy you would expect it to spare the forehead. When severe the patient will be unable to close their eye and may have problems keeping liquids in their mouth. The onset of facial weakness may be preceded by a 1-2 day history of mild facial/ear pain. If there is severe pain this may suggest Ramsay Hunt Syndrome (look for vesicles in ear).

Causes

Bell’s palsy is idiopathic but it is important to exclude other causes of a lower motor neurone facial nerve palsy including

Parotid mass – this would suggest a parotid malignancy
Ipsilateral ear infection – can be caused by otitis media or necrotising otitis externa which is mainly seen in elderly diabetics

Multiple cranial nerve palsies – this would suggest an alternative diagnosis such as a bulbar palsy or space occupying lesion

Who to refer, who not to refer, how to refer

If no improvement at 1 month refer to ENT as urgent via SCI Gateway
If parotid mass refer to ENT as urgent suspected cancer via SCI Gateway
If an associated infection refer to ENT same day via ENT@borders.scot.nhs.uk or ENT secretary 01896826128

Primary care management

Examination

Assess facial movement documenting ability to close eye. Using the House Brackman scale can be helpful and if the patient has a smart phone getting them to video themselves with their face at rest and then raising their eyebrows, closing the eye and smiling can be helpful to refer to in future.

Neck/parotid examination

Ear examination – look for vesicles suggesting Ramsay Hunt or signs of infection

Management

Prednisolone 25mg X2/day for 10 days

If any suggestion of Ramsay Hunt Syndrome oral acyclovir 400mg X5/day for 7 days

If unable to close eye easily

Tape eye closed at night
Lacrilube to eye at night
Hypromellose 2-3 eye drops X3/day

Local service details

ENT@borders.scot.nhs.uk