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Bell's palsy — peripheral facial palsy
Bell's palsy is a sudden one-sided palsy of the facial nerve, including the forehead; steroids within 72 hours improve recovery, and eye protection is essential — but a palsy that spares the forehead is central (stroke) and needs urgent transfer.
Why it matters in the exam
The exam presents a young woman with a drooping mouth corner that appeared in the last day and asks about treatment; a woman back from a trip to the US East Coast with facial palsy (Lyme disease); and a patient with ear vesicles (Ramsay Hunt). The questions test the difference between peripheral and central palsy and the treatment.
Remember that most patients recover fully, and that no improvement after 3 months, a gradual palsy, or recurrence on the same side require imaging to exclude a tumour.
Facial palsy frightens patients greatly, as they fear a stroke. Examining the forehead, the other cranial nerves and the limbs allows most to be reassured and the few who need imaging to be sent urgently.
Bell's palsy is more common in pregnancy and in diabetes, and steroids are allowed in pregnancy too. Another question describes a young woman with a drooping mouth corner and asks about treatment: prednisolone within 72 hours, eye drops and ointment, and an explanation that most patients recover fully within weeks to months. Bilateral palsy needs a work-up for Lyme disease, sarcoidosis and Guillain-Barré.
Key points
- Peripheral palsy involves the forehead; central spares it.
- Prednisolone within 72 hours.
- Eye protection — tears by day, ointment and taping at night.
- Ear vesicles — Ramsay Hunt; antivirals too.
- No improvement after 3 months — imaging.
Summary table
| Condition | What you see | What you do | Exam note |
|---|---|---|---|
| Bell's palsy (peripheral) | The whole half of the face including the forehead, onset within 72 hours | Prednisolone 50–60 mg a day for about 10 days (or 60 mg for 5 days then taper), started within 72 hours | Antivirals only as an add-on to steroids in severe palsy |
| Central palsy (stroke) | Forehead spared, sometimes arm weakness or speech disturbance | Urgent transfer, CT | Stroke — a time window for treatment |
| Ramsay Hunt syndrome | Ear vesicles, pain, hearing loss | Steroid and antiviral | Worse prognosis |
| Lyme disease | Stay in an endemic area, rash, sometimes bilateral | Serology | Doxycycline |
| Eye protection | Eyelid does not close | Artificial tears by day, ointment and taping at night | Danger of corneal ulcer |
| Follow-up | Most patients improve within 3 weeks | No improvement after 3 months, gradual worsening or recurrence — imaging and referral | 70–85% recover fully |
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Sources
- American Academy of Otolaryngology–Head and Neck Surgery Foundation, 2013 — Clinical practice guideline: Bell's palsy
- American Academy of Neurology, 2012 (reaffirmed) — Evidence-based guideline update: steroids and antivirals for Bell palsy
- Sullivan FM et al., New England Journal of Medicine, 2007 — Early treatment with prednisolone or acyclovir in Bell's palsy
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.