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Practice Practice Pointer

Assessment and management of facial nerve palsy

BMJ 2015; 351 doi: (Published 16 September 2015) Cite this as: BMJ 2015;351:h3725
  1. Liam Masterson, specialty registrar, ear, nose, and throat surgery1,
  2. Martin Vallis, general practitioner principal2,
  3. Ros Quinlivan, consultant, neuromuscular disease3,
  4. Peter Prinsley, consultant, ear, nose, and throat surgeon4
  1. 1Ear, Nose, and Throat Department, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, UK
  2. 2Rosedale Surgery, NHS Great Yarmouth and Waveney Clinical Commissioning Group, Lowestoft, UK
  3. 3MRC Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, London, UK
  4. 4Ear, Nose, and Throat Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
  1. Correspondence to: L Masterson lmm398{at}
  • Accepted 15 February 2015

The bottom line

  • In patients presenting with facial weakness, the first priority is to exclude an upper motor neurone lesion; important associated signs may include concurrent limb weakness, hyper-reflexia, upgoing plantars, or ataxia

  • Check for causes of a lower motor neurone lesion by examining the ears, mastoid region, oral cavity, eyes, scalp, and parotid glands

  • Bell’s palsy is a diagnosis of exclusion, and oral steroids are needed within 72 hours to increase the chance of complete recovery. Prognosis is usually good compared with other causes of lower motor neurone weakness, such as tumours and Ramsay Hunt syndrome

  • Eye protection is crucial if lid closure is impaired

How patients were involved in the creation of this article

We sought feedback on the paper from patient and medical representatives of the charity Facial Palsy UK. We incorporated their comments into the paper and developed a patient consultation guide for management and prognosis of Bell’s palsy (see box below)

The facial nerve is important for both communication and expression, and impairment of its function can severely affect quality of life.1 The main concern at first presentation of a facial nerve lesion is to exclude the possibility of a stroke or other serious cause.2 The figure outlines possible causes. Correct management within the first few days may prevent long term complications.

Differential diagnosis of a unilateral facial palsy. Percentages are based on combined epidemiological data from 6024 patients with lower motor neurone facial palsy (rarer conditions including mumps, syphilis, HIV, Guillain-Barré syndrome, otitic barotrauma, myasthenia gravis, systemic lupus erythematosus, sarcoidosis, and multiple sclerosis have been excluded).3 4 *Endemic in forested regions; †misdiagnosed cerebrovascular disease evident in about 1.5% of all patients3

How is it assessed?

The facial nerve is responsible for motor supply to the muscles of facial expression (frontalis, orbicularis oculi, buccinators, and orbicularis oris) and stapedius, parasympathetic supply to the lacrimal and submandibular glands, …

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