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Ear, nose and throat Neurological

Bell's palsy

Last revised in February 2023

Bell's palsy is an acute, unilateral, idiopathic, facial nerve paralysis. The paralysis also affects the eyelids, causing an impairment of blinking.

Bell's palsy: Summary

  • Bell's palsy is an acute, unilateral facial nerve weakness or paralysis of rapid onset (less than 72 hours) and unknown cause.
    • Herpes simplex virus, varicella zoster virus, and autoimmunity may contribute to the development of Bell's palsy, but the significance of these factors remains unclear.
  • Bell's palsy affects 20–30 people per 100,000 each year. It most common between 15 and 45 years of age.
  • Complications include eye injury, facial pain, dry mouth, intolerance to loud noises, abnormal facial muscle contraction during voluntary movements, and psychological sequelae.
  • A diagnosis of Bell's palsy can be made when no other medical condition is found to be causing facial weakness or paralysis. Symptoms include:
    • Rapid onset (less than 72 hours).
    • Facial muscle weakness (almost always unilateral) involving the upper and lower parts of the face. This causes a reduction in movement on the affected side, often with drooping of the eyebrow and corner of the mouth and loss of the nasolabial fold.
    • Ear and postauricular region pain on the affected side. 
    • Difficulty chewing, dry mouth, and changes in taste.
    • Incomplete eye closure, dry eye, eye pain, or excessive tearing.
    • Numbness or tingling of the cheek and/or mouth.
    • Speech articulation problems, drooling.
    • Hyperacusis.
  • Features atypical of Bell's palsy require referral for exclusion of an alternative diagnosis.
  • To manage Bell’s palsy:
    • The person should be advised to keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired.
    • For people presenting within 72 hours of the onset of symptoms, prescription of prednisolone should be considered.
    • Antiviral treatment alone is not recommended, but it may have a small benefit in combination with a corticosteroid; specialist advice is recommended if this is being considered.
  • Urgent referral should be arranged if nerve palsy may be caused by: 
    • An upper motor neurone cause.
    • Cancer. 
    • Acute systemic or severe local infection.
    • Trauma.
  • Referral to an appropriate specialist should be arranged if:
    • Ocular symptoms (for example, pain, irritation, or itch) develop at any time.
    • Atypical features are present. 
    • There is no improvement after 3 weeks of treatment. 
    • Existing neurologic findings worsen, or if new neurologic findings develop. 
    • There is incomplete recovery after 3 months of onset of symptoms.
  • Referral should be considered for people who: 
    • Have developed symptoms of aberrant reinnervation 5 months or more after the onset of Bell's palsy. 
    • May benefit from further support or counselling if there are emotional consequences of persistent facial paralysis or paresis.
  • Routine referral should not be arranged for adults with an uncomplicated episode of Bell's palsy. 

Have I got the right topic?

From age 16 years onwards.

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Suspected neurological conditions: recognition and referral [NICE, 2019], the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the Canadian Society of Otolaryngology - Head and Neck Surgery and Canadian Neurological Sciences Federation guideline Management of Bell palsy: clinical practice guideline [de Almeida et al, 2014], and the British Medical Journal (BMJ) Best practice guide Bell's palsy [BMJ, 2022].

This CKS topic covers the primary care management of Bell's palsy.

There is a separate CKS topic on Stroke and TIA. 

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

February 2023 — reviewed. A literature search was conducted in February 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. 

Previous changes

May 2019 — minor update. Recommendation on when to refer to a facial nerve specialist changed from incomplete recovery after 3 months to after 5 months. In line with NICE guideline Suspected neurological conditions: recognition and referral.

August to September 2018 — reviewed. A literature search was conducted in July 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. New sections on complications and differential diagnosis have been added. There have been changes to the recommendations on use of antiviral treatment in combination with corticosteroids and referral. Links to patient information are now included.

October 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made, but an additional corticosteroid dosing option has been added to the section on treatment.

July to September 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 February 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 February 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 February 2023.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analyses published since 1 February 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 February 2023.

New policies

No new national policies or guidelines since 1 February 2023.

New safety alerts

No new safety alerts since 1 February 2023.

Changes in product availability

No changes in product availability since 1 February 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make an accurate diagnosis of Bell's palsy.
  • Initiate appropriate treatment.
  • Refer appropriately to secondary care or other specialist services.
  • Provide appropriate advice.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Bell's palsy is an acute, unilateral facial nerve weakness or paralysis of rapid onset (less than 72 hours) and unknown cause [Baugh, 2013].  

What causes it?

  • The cause of Bell's palsy is unknown [Baugh, 2013; Phan, 2016].  
    • Weakness and paralysis may be due to inflammation and oedema of the facial nerve causing nerve compression and temporary or permanent damage during its passage through the temporal bone [Baugh, 2013; Glass, 2014].  
    • Herpes simplex virus, herpes zoster virus, and autoimmunity may contribute to the development of Bell's palsy, but the exact pathogenesis is controversial and the significance of these factors remains unclear [de Almeida et al, 2014; Zandian, 2014; Eviston, 2015; BMJ, 2022]. 

How common is it?

  • Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis [Baugh, 2013] and accounts for around 8 out of 10 facial mononeuropathies [Zandian, 2014]. 
  • Men and women are equally affected [Eviston, 2015]. 
  • It occurs more commonly in people who [Baugh, 2013; Phan, 2016]:  
    • Are aged between 15 and 45 years.
    • Have diabetes, are immunocompromised, are obese, have hypertension, or upper respiratory conditions.
    • Are pregnant — pregnant women, particularly in the third trimester and in the first 2 weeks postpartum, are at 2 to 4 times at higher risk of developing Bell's palsy compared to women who are not pregnant [Evangelista, 2019]. 

What are the complications?

  • Complications of Bell's palsy include:
    • Eye injury, corneal ulceration, and vision loss (because of an inability to close the eyelid), ectropion, gustatory hyperlacrimation [Baugh, 2013; de Almeida et al, 2014; BMJ, 2022].   
    • Facial pain and paraesthesia [Glass, 2014]. 
    • Dry mouth because of loss of parasympathetic innervation to the submandibular and sublingual salivary glands [Glass, 2014].  
    • Intolerance to loud noises if the nerve branch to stapedius is affected [Glass, 2014].  
    • Synkinesis — abnormal facial muscle contraction during voluntary movements (for example, facial spasms such as involuntary eye closure during midface movement, or lip movement when the eyes close), possibly as a result of unusual reinnervation of the facial musculature [de Almeida et al, 2014; Glass, 2014; Eviston, 2015].  
    • Reduced quality of life and psychological complications — diminished facial movement and facial asymmetry can impair interpersonal relationships, cause social distress,  social alienation, anxiety and depression [Baugh, 2013; Glass, 2014].  

What is the prognosis?

  • Most people with Bell's palsy begin to recover, even without treatment, within 2–3 weeks. Complete recovery usually occurs within 3–4 months [Baugh, 2013].  
    • In terms of facial function, the likelihood of significant improvement is associated with the initial severity of facial weakness [de Almeida et al, 2014]. 
    • Over 90% of people with incomplete paralysis, and about 70% of people with complete paralysis, recover completely within 6 months, even without intervention [Baugh, 2013].  
    • If treated with prednisolone within 72 hours of symptom onset 83% of people fully recover facial motor function after 6 months or more, with most showing improvement from 3 weeks, compared to 72% for people who do not receive treatment within 72 hours [Madhok, 2016; Butler, 2019, Facial palsy: when and why to refer for specialist care]. 
  • Moderate to severe long-term sequelae are experienced by 16% of people [Glass and Tzafetta, 2014].
  • Other factors affecting prognosis include [Stew, 2013]:  
    • Rate of recovery — signs of improvement within 2 weeks indicate a more positive long-term prognosis.
    • Age — younger people are more likely to have better outcomes.
    • Timing of treatment — initiation of steroids within 72 hours improves prognosis. 
    • Pregnancy — the course is typically more severe, and pregnant women are more likely to develop complete facial paralysis with incomplete resolution [Evangelista, 2019]. 
  • Around 6.5% of people experience recurrence of Bell's palsy with half experiencing recurrence within 5 years. Complete recovery occurs in 66% of people with recurrent Bell's palsy [Dong, 2019].  

Diagnosis of Bell's palsy

When should I suspect Bell's palsy?

  • A diagnosis of Bell's palsy can be made when no other medical condition is found to be causing facial weakness or paralysis. 
  • Symptoms suggestive of Bell's palsy include: 
    • Rapid onset (less than 72 hours). 
    • Facial muscle weakness or paralysis (almost always unilateral) involving the upper and lower parts of the face — this causes a reduction or complete loss of movement on the affected side, sagging of the eyelid or corner of the mouth, drooping of the eyebrow and corner of the mouth, and loss of the nasolabial fold.
    • Ear and postauricular region pain on the affected side (in around half of people with Bell's palsy).
    • Difficulty chewing, dry mouth (in 20% of people), and changes in taste (in around 35% of people).
    • Poor to incomplete eye closure, dry eye (in 30% of people), eye pain, or excessive tearing.
    • Hyperacusis (in less than 5% of people).
    • Numbness or tingling of the cheek and/or mouth. 
    • Speech articulation problems, drooling.
  • Atypical features of Bell's palsy require referral for exclusion of an alternative diagnosis, and include: 
    • Gradual progression — this is more likely to be associated with a neoplastic or infectious cause of facial palsy. 
    • Insidious onset, pain within facial nerve distribution, persistent facial paralysis for over 6 months, or ipsilateral hearing loss — may indicate head or neck cancer. 
    • Parotid mass.
    • Predisposing factors for facial palsy, for example, previous stroke, brain tumour, parotid tumour, skin cancers of the head or face, facial/head trauma or recent infections. 
    • Systemic illness or fever. 
    • Vestibular abnormalities (for example dizziness). 
    • Diplopia. 
    • Dysphagia. 
    • Hearing abnormalities other than mild to moderate otalgia, hyperacusis, and postauricular pain (for example ipsilateral deafness, tinnitus, fullness or discharge).
    • Sparing of brow function (ability to raise the eyebrow on the affected side) — may indicate an upper motor neurone lesion (such as stroke).
    • Paralysis of individual branches of the facial nerve or other cranial nerve involvement. 
    • Uneven distribution of weakness across facial zones — if this occurs in the acute phase it is highly suggestive of a neoplasm in the parotid, or along the course of the facial nerve. 
    • Synkinesis with facial weakness in the acute phase — this is highly suggestive of an alternative diagnosis, such as a neoplastic process. 
    • Bilateral signs — may be indicative of Lyme disease or sarcoidosis. 
    • A recurrent episode. 
    • Vesicular skin rashes (indicative of herpes zoster), or ulcerative skin lesions (suggestive of skin cancer). 

Basis for recommendation

These recommendations are based on the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the British Medical Journal (BMJ) Best Practice guide Bell's palsy [BMJ, 2022], and expert opinion in narrative reviews Bell’s palsy syndrome: mimics and chameleons [Fuller, 2016], Assessment and management of facial nerve palsy [Masterson, 2015], and Bell’s palsy: aetiology, clinical features and multidisciplinary care [Eviston, 2015]. 

Identifying atypical features

  • The importance of identifying atypical features and their significance is emphasised in the AAO-HSNF guideline which notes that symptoms and signs atypical of Bell's palsy may require specialist and in-depth testing and imaging [Baugh, 2013]. 

How should I assess a person with suspected Bell's palsy?

  • Take a history and ask about:
    • Onset, progression and any precipitating factors (for example, head or facial trauma, upper respiratory tract infection).  
    • Associated symptoms — for example, malaise, fever, rash, headache, myalgia, arthralgia, cranial neuropathies (such as double vision, hoarseness), or ear symptoms (such as tinnitus, hearing loss, vertigo). 
    • Previous episodes of facial palsy, facial, lip, or parotid swelling or uveitis. 
    • Current, or previous malignancy. 
    • Comorbidities and current medication — for example, HIV, immunosuppression, autoimmune disorders, neurotoxic medicines. 
    • Current pregnancy, or recent delivery. 
    • Recent travel — for example to a Lyme disease endemic area.
    • Recent head trauma. 
  • Perform a focused neurological examination and a complete head and neck examination to identify features suggesting an alternative cause of facial palsy. This should include examination of the:
    • Cranial nerve.
    • Ear canal, tympanic membrane — perform otoscopy, and Weber's and Rinne's tuning fork tests. 
    • Parotid gland — palpate the parotid gland, and visually examine the oropharynx to rule out a deep lobe parotid tumour, which may displace the tonsil medially.
    • Skin of the head, face, cheek, oral cavity, mastoid region — to check for a skin rash, nodules, or vesicles, ulcerative lesions, bruises or swelling.
    • Eyes and periocular complex. 
  • Routine laboratory tests and diagnostic imaging are not required in primary care for new-onset Bell's palsy. 
  • A diagnosis of Bell's palsy can be made when no other medical condition is found to be causing facial weakness or paralysis. 
    • Apart from uniformly distributed one-sided facial palsy, the physical examination should be unremarkable. 

Basis for recommendation

These recommendations are based on the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the British Medical Journal (BMJ) Best Practice guide Bell's palsy [BMJ, 2022], and expert opinion in narrative reviews Assessment and management of facial nerve palsy [Masterson, 2015], and Medical management of acute facial paralysis [O, 2018].

What else might it be?

  • Other causes of facial weakness and paralysis include:
    • Stroke — forehead spared, extremities often affected. For more information, see the CKS topic on Stroke and TIA.
    • Brain tumour — possible history of cancer, mental state changes, gradual onset. For more information, see the CKS topic on Brain and central nervous system cancers - recognition and referral.
    • Traumatic injury to the facial nerve (for example, basal skull fracture, or as a consequence of surgery) — suggested by history and signs such as bruises or scars.
    • Facial nerve tumour, parotid tumours — may be uneven distribution of weakness across facial zones, with gradual onset of symptoms and palpable mass.  
    • Skin cancer — there may be ulcerative skin lesions. For more information, see the CKS topic on Skin cancers - recognition and referral. 
    • Infectious causes:
      • Herpes simplex — history of fever and malaise. 
      • Lyme disease — may cause bilateral symptoms. Associated with a history of tick exposure, rash (bullseye lesion in 70%), and arthralgia. For more information, see the CKS topic on Lyme disease. 
      • Otitis media — otalgia, conductive hearing loss, gradual onset. For more information, see the CKS topic on Otitis media - acute.
      • Mastoiditis — mastoid region tender or swollen. 
      • Cholesteatoma — foul smelling otorrhoea, conductive hearing loss, otalgia, fever. For more information, see the CKS topic on Cholesteatoma.
      • Ramsay Hunt syndrome — pain followed by vesicular rash on the pinna, or in the ear canal or pharynx. Associated with sensorineural hearing loss.
      • Encephalitis/meningitis — headache, neck stiffness. For more information, see the CKS topic on Meningitis - bacterial meningitis and meningococcal disease.
      • HIV — fever, malaise, CD4 count. For more information, see the CKS topic on HIV infection and AIDS.
      • Syphilis — other neurological and skin symptoms and signs. For more information, see the CKS topic on Syphilis.
      • Glandular fever — malaise, few distinguishing characteristics. For more information, see the CKS topic on Glandular fever (infectious mononucleosis).
    • Diabetes — history of, or other symptoms and signs of diabetes. Suggestive laboratory test results. For more information, see the CKS topics on Diabetes - type 1 and Diabetes - type 2.
    • Multiple sclerosis — intermittent symptoms and additional neurological symptoms. For more information, see the CKS topic on Multiple sclerosis.
    • Guillain-Barré — ascending paralysis, weakness of hands and feet, then trunk. 
    • Sarcoidosis — symptoms may be bilateral, suggestive laboratory test results (angiotensin-converting enzyme level).
    • Arteriovenous malformation.

Basis for recommendation

This information is based on the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the British Medical Journal (BMJ) Best Practice guide Bell's palsy [BMJ, 2022], and expert opinion in narrative reviews Assessment and management of facial nerve palsy [Masterson, 2015], and Medical management of acute facial paralysis [O, 2018].

Management

Scenario: Management of Bell's palsy

From age 16 years onwards.

How should I manage a person with Bell's palsy?

  • 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 50 mg daily for 10 days or
    • Giving 60 mg daily for 5 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. 
  • Antiviral treatments alone are not recommended. 
    • Antiviral treatment in combination with a corticosteroid may be of small benefit, but seek specialist advice if this is being considered. 
  • For all people with Bell's palsy provide information and advice about the prognosis and self-care.

Basis for recommendation

These recommendations are based on the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the Canadian Society of Otolaryngology - Head and Neck Surgery and Canadian Neurological Sciences Federation guideline Management of Bell palsy: clinical practice guideline [de Almeida et al, 2014], and the British Medical Journal (BMJ) Best Practice guide Bell's palsy [BMJ, 2022].

Corticosteroid treatment 
  • A Cochrane systematic review showed significant benefits with corticosteroid treatment for Bell's palsy [Madhok, 2016].  
    • The main outcome measure was incomplete recovery of facial motor function or residual weakness. Seven trials (n = 895) showed that, in the corticosteroid group, 17% had incomplete recovery of motor function compared with 28% in the control group of people receiving no effective treatment for Bell's palsy (risk ratio [RR] 0.63, 95% CI 0.50 to 0.80). The number needed to treat with corticosteroids to prevent one case of incomplete recovery was 10.
    • Other outcome measures were:
      • Reduction in cosmetically disabling sequelae after 6 months. Low-quality evidence from two trials (n = 75) showed a similar effect with corticosteroid treatment compared with placebo (RR 0.96, 95% CI 0.40 to 2.29).
      • Motor synkinesis (involuntary facial movement) and crocodile tears. Three moderate-quality trials (n = 485) identified a reduction in motor synkinesis in the corticosteroid group (RR 0.64, 95% CI 0.45 to 0.91).
    • In terms of adverse effects, data from three trials (n = 715) found no significant difference between the corticosteroid and placebo groups (RR 1.04, 95% CI 0.71 to 1.51).
  • A systematic review and meta-analysis which compared standard-dose corticosteroids with high-dose corticosteroids found that higher-dose corticosteroids reduced non-recovery in people with Bell’s palsy, but did not identify a suitable dose [BMJ, 2022]. 
Antiviral treatment alone
  • Oral antiviral treatment alone is not recommended [Baugh, 2013; de Almeida et al, 2014]. 
  • A recent Cochrane systematic review found that corticosteroids alone were probably more effective than antivirals alone with regard to recovery rates, but there was no clear benefit of antivirals alone over placebo [Gagyor, 2019].

Antiviral treatment plus corticosteroids

  • Combined corticosteroid and antiviral treatment is not routinely recommended for people with Bell's palsy, because there is insufficient evidence to support its use compared with corticosteroids alone.
  • A Canadian clinical practice guideline advises not to combine corticosteroids and antiviral treatment for people with mild to moderate severity Bell's palsy, having calculated a number needed to treat for one fewer episode of unsatisfactory facial recovery of 100, but suggests their use if there is severe to complete paresis on the basis of calculating a number needed to treat of 14 in this group [de Almeida et al, 2014]. 
  • The AAO-HNSF guideline development group gives clinicians the option of offering antiviral treatment in addition to oral corticosteroids within 72 hours for people with Bell's palsy, on the basis that there is a small potential improvement in the function of the facial nerve, while acknowledging that there is no proven benefit from large, high-quality clinical trials [Baugh, 2013].  
    • The guideline development subcommittee of the American Academy of Neurology concluded that, for people with new-onset Bell's palsy, combination treatment with corticosteroids and antivirals should be offered because of the possibility of a modest improvement in recovery compared with corticosteroids alone. They noted, however, that any potential benefit is small and not well established [Gronseth, 2012].  
  • A Cochrane systematic review found that [Gagyor, 2019]:
    • The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, and there may be no clear difference with the combination therapy compared to corticosteroids alone among people with severe Bell's palsy, however, the results were very imprecise.  
    • Corticosteroids alone were probably more effective than antivirals alone in terms of recovery rates, and antivirals plus corticosteroids were more effective than placebo or no treatment. 
    • The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone.
  • A more recent systematic review that compared pharmacological treatments for Bell's palsy in adults found moderate- to high-quality evidence in a network meta-analysis of 7 RCTs (n = 1293) that combined therapy (with an antiviral and corticosteroid) was the only efficacious regimen for the secondary outcome, synkinesis (RR of 0.35; 95% credible interval: 0.19 to 0.65) [Jalali, 2021].  
    • For the primary outcome, good recovery, there was low- to very-low-quality evidence that combined therapy may have higher good recovery rates in short- and intermediate/long-terms compared to placebo (small effect size).
    • However, the study authors note that further RCTs and studies with considerably longer follow-ups are needed to confirm the results.
  • Although the risks and adverse effects of antiviral treatment are minimal [Albers, 2014], because of the lack of UK guidelines, low-quality evidence and conflicting recommendations between existing clinical practice guidelines [Baugh, 2013; de Almeida et al, 2014], uncertainty about the optimal antiviral drug and dosing regimen [de Almeida et al, 2014; Phan, 2016], the recommendation to seek specialist advice if combination treatment is being considered is pragmatic based on what CKS considers good medical practice.
Physical therapy
  • CKS was unable to make a recommendation on physical therapy for Bell's palsy because of a lack of evidence to support its use. The AAO-HNSF and consensus Canadian guideline also found insufficient consistent evidence on which to make a recommendation regarding physical therapy [Baugh, 2013; de Almeida et al, 2014].  
  • A Cochrane systematic review of physical therapy for Bell's palsy discussed 12 studies [Teixeira, 2011].
    • Therapies studied included electrical stimulation, exercises, massage, infrared treatment, and physical therapy with acupuncture.
    • No high-quality evidence was identified, so it is difficult to draw any conclusions. Low-quality evidence suggests that facial exercises may reduce sequelae in acute cases, but the authors discussed the need to confirm this with good-quality randomized controlled trials.
  • A subsequent review also found insufficient good-quality evidence on which to base firm conclusions on the role of physical therapy combined with standard drug treatment in the management of Bell's palsy [Ferreira, 2015].  
  • A more recent systematic review found some evidence to support the use of facial exercise in people with Bell's palsy. However, the heterogeneous nature of the included studies made it impossible to pool data from individual studies to increase the power and precision of estimates of treatment effects and limited the ability to draw a clear correlation between the effectiveness of facial exercise therapy and time since onset of facial palsy, clinical severity, or other patient demographics [Khan, 2022].    

What advice should I give a person with Bell's palsy?

  • Advise the person that Bell's palsy improves at different rates and maximum recovery can take several months. 
  • Advise the person about eye care:
    • It is important to keep the affected eye lubricated. Lubricating eye drops should be used frequently during the day and eye ointment used at night. 
      • A large range of tear replacement and ocular lubricant products are available on prescription or over the counter. 
    • If they are unable to close the eye at bedtime, they should tape it closed using microporous tape. 
      • Note: eye patches are contraindicated as the eye may open under the patch leading to corneal abrasion. 
    • Wearing sunglasses when outdoors, can help protect the eye. 
    • Situations that may cause eye irritation such as swimming and dusty environments should be avoided if possible. 
    • If they experience eye irritation, pain, itching or vision changes, they should seek immediate medical advice. 
  • If facial weakness or paralysis affects eating, suggest using a straw for liquids and advise eating soft foods. 
  • Offer the person written advice or signpost to other sources of information, such as the Facial Palsy UK leaflet Bell's Palsy, or the NHS website information on Bell's palsy. 

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected neurological conditions: recognition and referral [NICE, 2019], the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the British Medical Journal (BMJ) Best Practice guide Bell's palsy [BMJ, 2022], and expert opinion in narrative reviews Assessment and management of facial nerve palsy [Masterson, 2015], and Medical management of acute facial paralysis [O, 2018], Bell’s palsy: aetiology, clinical features and multidisciplinary care [Eviston, 2015], and what CKS considers good medical practice.  

When should I refer someone with Bell's Palsy?

  • Refer people urgently if clinical features, history and examination suggest facial nerve palsy may be caused by:  
    • An upper motor neurone cause (for example limb paresis, facial paraesthesia, other cranial nerve involvement, postural imbalance). 
      • Arrange immediate emergency admission for people with suspected stroke. For more information, see the CKS topic on Stroke and TIA.
    • Cancer (for example, gradual onset of symptoms, persistent facial paralysis for more than 6 months, pain in the distribution of the facial nerve, head or neck lesion suggestive of cancer, history of head and neck cancer, hearing loss on the affected side). 
      • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks). 
    • Trauma.
    • Acute systemic or severe local infection.  
  • Refer other people to an appropriate facial nerve specialist (for example, a neurologist, or ear, nose and throat specialist) with urgency determined by clinical judgment, if:
    • Atypical features are present. 
    • There is no improvement after 3 weeks of treatment. 
    • Existing neurologic findings worsen, or if new neurologic findings develop. 
    • There is incomplete recovery after 3 months of onset of symptoms. 
    • The diagnosis is uncertain. 
  • Refer people to an ophthalmologist if ocular symptoms develop at any time (for example, pain, irritation, or itch).  
    • Provide advice on eye care measures while awaiting referral.
  • Consider referring adults with Bell's palsy who have developed symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking) 5 months or more after the onset of Bell's palsy for neurological assessment and possible treatment. 
  • Consider referral for further support or counselling if there are emotional consequences of persistent facial paralysis or paresis. 
  • Do not routinely refer adults with an uncomplicated episode of Bell's palsy (unilateral lower motor neurone pattern facial weakness affecting all parts of the face and including weakness of eye closure) and no evidence of another medical condition such as middle ear disease.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected neurological conditions: recognition and referral [NICE, 2019], the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the Canadian Society of Otolaryngology - Head and Neck Surgery and Canadian Neurological Sciences Federation guideline Management of Bell palsy: clinical practice guideline [de Almeida et al, 2014], and expert opinion in narrative reviews Assessment and management of facial nerve palsy [Masterson, 2015], The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends [Zandian, 2014], and Optimising treatment of Bell’s palsy in primary care: the need for early appropriate referral [Glass, 2014].

Referral
  • The recommendation to refer people if there has been no improvement after 3 weeks is based on a Canadian guideline [de Almeida et al, 2014], and expert opinion in narrative reviews [Zandian, 2014; Glass, 2014] and what CKS considers good medical practice, as most people with Bell's palsy begin to recover, even without treatment, within 2–3 weeks. 
    • Laboratory and imaging studies are not routinely needed in the diagnosis of Bell’s palsy and are only recommended in patients with recurrence, or if there has been no improvement after more than 3 weeks of therapy [Zandian, 2014]. 
    • All acute cases of Bell’s palsy exhibiting residual symptoms after a few weeks should be considered for referral [Glass, 2014].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Prescribing corticosteroids

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Suspected neurological conditions: recognition and referral [NICE, 2019], the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) guideline Bell's palsy [Baugh, 2013], the Canadian Society of Otolaryngology - Head and Neck Surgery and Canadian Neurological Sciences Federation guideline Management of Bell palsy: clinical practice guideline [de Almeida et al, 2014], and the British Medical Journal (BMJ) Best practice guide Bell's palsy [BMJ, 2022]. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of Bell's palsy.

Search dates

July 2018 - March 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

  • (MH "Bell Palsy") 
  • AB (bell* N1 pals*) OR TI (bell* N1 pals*)
  • AB ( (facial N3 (palsy or palsies or paralysis or neuropathy)) ) OR TI ( (facial N3 (palsy or palsies or paralysis or neuropathy)) ) 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Albers, J.R. and Tamang, S. (2014) Common questions about Bell palsy. American Family Physician 89(3), 209-212. [Abstract] [Free Full-text]
  • Baugh, R.F., Basura, G.J., Ishii, L.E., et al. (2013) Clinical practice guideline: Bell's palsy. Otolaryngology - Head and Neck Surgery 149(3 Suppl), S1-S27. [Abstract]
  • BMJ Best Practice (2022) Bell's palsy. BMJ Publishing. https://bestpractice.bmj.com/info
  • Butler, D.P., Morales, D.R., Johnson, K. et al. (2019) Facial palsy: when and why to refer for specialist care. British Journal of General Practice 69(688), 579-580. [Abstract]
  • de Almeida, J.R., Guyatt, G.H. and Sud, S. et al (2014) Management of Bell palsy: clinical practice guideline. Canadian Medical Association journal 186(12), 917-922. [Abstract]
  • Dong, S.H., Jung, A.R., Jung, J. et al. (2019) Recurrent Bell's palsy. Clinical Otolaryngology 44(3), 305-312. [Abstract]
  • Evangelista, V., Gooding, M.S. and Pereira, L. (2019) Bell’s palsy in pregnancy. Obstetrical and Gynecological Survey 74(11), 674-678. [Abstract]
  • Eviston, T.J., Croxson, G.R., Kennedy, P.G., et al. (2015) Bell's palsy: aetiology, clinical features and multidisciplinary care. Journal of Neurology, Neurosurgery and Psychiatry 86(12), 1356-1361. [Abstract] [Free Full-text]
  • Ferreira, M., Marques, E.E., Duarte, J.A. and Santos, P.C. (2015) Physical therapy with drug treatment in Bell palsy: a focused review. American Journal of Physical Medicine and Rehabilitation 94(4), 331-340. [Abstract]
  • Fuller, G. and Morgan, C. (2016) Bell's palsy syndrome: mimics and chameleons. Practical Neurology 16(6), 439-444. [Abstract]
  • Gagyor, I., Madhok, V.B., Daly, F. et al. (2019) Antiviral treatment for Bell's palsy (idiopathic facial paralysis) (Cochrane Review). Issue 9. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Glass, G.E. and Tzafetta, K. (2014) Bell's palsy: a summary of current evidence and referral algorithm. Family Practice 31(6), 631-642. [Abstract]
  • Glass, G.E. and Tzafetta, K. (2014) Optimising treatment of Bell’s palsy in primary care: the need for early appropriate referral. British Journal of General Practice 64(629), e807-e809. [Abstract] [Free Full-text]
  • Gronseth, G.S., Paduga, R. and American Academy of Neurology (2012) Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 79(22), 2209-2213. [Abstract]
  • Jalali, M.M., Soleimani, R., Soltanipour, S. et al. (2021) Pharmacological treatments of Bell’s palsy in adults: a systematic review and network meta-analysis. The Laryngoscope 131(7), 1615-1625. [Abstract]
  • Khan, A.J., Szczepura, A., Palmer, S. et al. (2022) Physical therapy for facial nerve paralysis (Bell’s palsy): an updated and extended systematic review of the evidence for facial exercise therapy. Clinical Rehabilitation 36(11), 1424-1449. [Abstract]
  • Madhok, V.B., Gagyor, I., Daly, F., et al. (2016) Corticosteroids for Bell's palsy (idiopathic facial paralysis) (Cochrane Review). Issue 5. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Masterson, L., Vallis, M., Quinlivan, R. and Prinsley, P. (2015) Assessment and management of facial nerve palsy. BMJ 351, h3725. [Abstract]
  • NICE (2019) Suspected neurological conditions: recognition and referral. National Institute of Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • O, T.M. (2018) Medical management of acute facial paralysis. Otolaryngologic Clinics of North America 51(6), 1051-1075. [Abstract]
  • Phan, N.T., Panizza, B. and Wallwork, B. (2016) A general practice approach to Bell's palsy. Australian Family Physician 45(11), 794-797. [Abstract] [Free Full-text]
  • Stew, B. and Williams, H. (2013) Modern management of facial palsy: a review of current literature. British Journal of General Practice 63(607), 109-110. [Abstract]
  • Teixeira, L.J., Valbuza, J.S. and Prado, G.F. (2011) Physical therapy for Bell's palsy (idiopathic facial paralysis) (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
  • Zandian, A., Osiro, S. and Hudson, R. (2014) The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends. Medical Science Monitor 20, 83-90. [Abstract] [Free Full-text]
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