Facial nerve palsy, commonly called Bell's palsy, is a sudden weakness of the muscles of one half of the face caused by dysfunction of the facial nerve. Closing the eye on the affected side becomes difficult, the corner of the mouth droops, liquid escapes while drinking, and there may be pain behind the ear, altered hearing or sound sensitivity, and changed taste at the front of the tongue. The weakness involves the forehead, eye and mouth on the same side, and usually develops over hours to a day or two. The most important distinction in the first minutes is between peripheral facial palsy and a stroke. In Bell's palsy the whole half of the face is affected, forehead included, and there is no limb weakness. If the forehead is spared and the eyebrow can still be raised, or if the facial weakness comes with slurred speech, arm or leg weakness, or altered awareness, this is an emergency and the patient must go to the emergency department immediately, because stroke treatment has a narrow time window. Management of Bell's palsy depends on starting early. Oral corticosteroid is prescribed as soon as possible, ideally begun within the first three days of symptom onset, and an antiviral agent is added in selected cases at the clinician's discretion. Alongside this comes eye protection, which is the single most important step in preventing permanent damage: lubricating drops during the day, ointment and taping or a patch at night, because an eye that cannot close is at risk of corneal ulceration. Neuromuscular facial rehabilitation with mirror exercises and coordinated-movement training then follows. The limits should be stated plainly. No treatment guarantees a faster return of nerve function. Most patients recover well, but a proportion is left with residual weakness or unwanted linked movements. Antibiotics have no role in Bell's palsy, there is no strong evidence that early electrical stimulation speeds recovery, and vigorous massage does not help. The popular belief that cold air or air conditioning causes the condition is not established, and the more harmful belief is that one should simply wait for spontaneous recovery, which wastes the early treatment window. Whether and how you are treated is decided by clinical examination, not by reading.
Procedure steps
- 1
Urgent assessment and stroke exclusion
The clinician tests eyebrow elevation, eye closure and mouth movement to establish whether the forehead is involved, and examines limbs, speech and balance. Any central sign, limb weakness or slurred speech sends the patient to the emergency department for stroke assessment. The ear canal and parotid region are also examined for shingles, infection or a mass.
- 2
Prompt initiation of medication
Oral corticosteroid is started at the earliest opportunity, preferably within the first three days, with an antiviral added in selected cases such as severe palsy or suspected herpes zoster of the ear. Diabetes, hypertension and peptic ulcer disease are reviewed before prescribing, and expected effects and treatment duration are explained.
- 3
Protecting the eye from ulceration
Lubricating drops are prescribed for frequent use during the day, with ointment at night plus eye covering or lid taping, and sunglasses outdoors. The patient is taught to close the lid manually at intervals, and is referred to an ophthalmologist at the first sign of redness, pain or blurred vision.
- 4
Neuromuscular facial rehabilitation
Rehabilitation begins with gentle mirror exercises focused on isolated, coordinated movements rather than forceful straining, together with training for chewing, speech and drinking, and strategies to limit unwanted linked movements. The programme is supervised, progresses as movement returns, and avoids over-effort, which can worsen synkinesis.
- 5
Follow-up and further testing if recovery stalls
Review appointments document severity on a standard grading scale. If clear improvement has not begun within several weeks, or if weakness progresses gradually, affects both sides, or recurs on the same side, nerve conduction studies and imaging of the brain and facial nerve are requested to look for another cause requiring different treatment.
Before the procedure
Do not delay assessment to wait for spontaneous recovery: record precisely the hour or day the symptoms started, because the decision about medication depends on that timing. Before the visit, try in front of a mirror to raise your eyebrow and close your eye tightly, and take a photo or short video while attempting to smile and close the eye, which helps measure improvement later. Tell the doctor about any fever, ear pain, or blisters and rash around or inside the ear canal, and about recent head injury or ear surgery. Report your chronic conditions, particularly diabetes, hypertension, peptic ulcer disease and glaucoma, list all your medicines, and mention pregnancy or breastfeeding, since all of these affect the choice of treatment, its dosing and how you are monitored.
After the procedure
Complete the full course of medication as prescribed and do not stop halfway because you feel better, and keep protecting the eye until closure is complete: frequent drops during the day, ointment and covering at night, and glasses outdoors or in wind. Eat soft food and chew slowly on the unaffected side to avoid biting your cheek, drink through a straw if your lips do not seal, and clean the pocket between cheek and gum after meals, as food collects there. Exercise gently in front of the mirror as instructed, and do not strain or vigorously massage the facial muscles. Monitor blood glucose if you have diabetes, since corticosteroids raise it. **Seek care urgently for eye pain, redness, a gritty sensation or blurred vision, painful blisters or rash around the ear, fever with severe headache or neck stiffness, new arm or leg weakness or slurred speech, weakness affecting both sides, or worsening weakness after two weeks of treatment.**
Expected duration
The first visit is urgent and ideally within 72 hours of onset; medication usually runs 10 to 14 days; improvement typically begins between two and three weeks and may continue for six months or longer.
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