Facial Nerve Palsy (Adult)

Accurate history regarding timing and associated symptoms. The majority of cases (55%) are Bell’s palsy but this is a diagnosis of exclusion and therefore other reversible causes need to be ruled out. History and examination to diagnose:

• CVA or acute neurological cause – Other neurological symptoms +/- forehead sparing
• Infection - Other otological symptoms and signs of discharge or polyp in Ear canal
• Head trauma – History of trauma or signs of skull base fracture.
• Masses in the parotid or neck
• Ramsay Hunt - Vesicles around the pinna or palate, with significant pain often neurological

If all of the above have been excluded then the diagnosis of Bell’s palsy is likely. Try to score the facial nerve palsy using the House-Brackman scoring method. Start facial exercises as per link.

Eye Care is an essential part of the initial management.

• Taping the eye shut overnight and regular lubrication (viscotears)
• Urgent referral to ophthalmology as below maybe needed.

Steroids as per ENT UK and NICE guidance.

• Within 5 days of onset oral prednisolone OD 1mg per kg up to 60mg with PPI cover for 5 days then reduce by 10mg a day until stopped.
• If between 5-10 days from onset steroids may help but less evidence so discussion with patient needed.

Anti viral

• If House-Brackmann grade 5-6 (complete or almost complete paralysis) or vesicles in the ear or palate then likely (Ramsay Hunt) then add aciclovir 800mg 5 times a day for 7 days.

Acute

• CVA or other acute neurological cause suspected (Emergency referral to the on call Medical team)
• Suspected otological infection (including Ramsay Hunt) or cholesteatoma (Emergency referral to on call ENT team Ninewells bleep 4496)
• Head and neck mass or malignancy suspected (Urgent written referral to ENT team)
• If trauma is suspected the patient needs to be discussed and assessed for via A+E and the trauma team.

No significant recovery at 6 weeks or recurrent episodes

• If recovery is incomplete at 6 weeks or recurrent palsy then routine referral to ENT at this stage to rule out other potential causes.

Recurring Bell's palsy

• Start above initial management and routine referral to ENT for investigation of alternative diagnosis even if good recovery.

• PIL in progress
• Patient support and exercises

• Scottish New England Journal of Medicine paper – Evidence for steroids
• Family practice Bell’s palsy summary
• British Journal of GPs
• NICE guidance
• ENT UK Bell’s palsy guidance