If you suspect that you have Bell’s palsy, then you should visit your GP or attend A & E as soon as possible. It is important to seek medical advice within 72 hours of onset, as research indicates that this is the optimum period of time in which Bell’s palsy will successfully respond to treatment.
Having Bell’s palsy can be a frightening and confusing time and a person with Bell’s palsy may initially fear that they are having a stroke. In Bell’s palsy, however, the paralysis affects the entire half of the face, including the forehead (whereas typically with a stroke, the forehead is spared). Also, in Bell’s palsy there is no weakness of the hands, arms or legs. If you are worried that a person has had a stroke or TIA (transient ischaemic attack or ‘mini’ stroke), think of the word FAST (this stands for Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services). For further information on the differences between Bell’s palsy and stroke, please see our page on stroke.
What is Bell’s palsy?
The name ‘Bell’s palsy’ comes from 19th-century Scottish anatomist and surgeon Sir Charles Bell, who discovered that severing the seventh cranial (or facial) nerve causes facial paralysis.
- In Bell’s palsy there is inflammation around the facial nerve and this pressure causes facial paralysis on the affected side.
- Facial nerve palsy is the most common acute condition involving only one nerve, with Bell’s palsy being the most common cause of acute facial paralysis.
- Bell’s palsy is the commonest cause of facial palsy, accounting for approximately 80 per cent of all cases. It affects between 20 per 100,000 to 30 per 100,000 people per year. It is difficult to know the exact incidence of Bell’s palsy as not all people with the condition are diagnosed or recorded. The average GP will see a case every 2 years.
- NICE Clinical Knowledge Summaries May 2019 states that Bell’s palsy occurs most commonly between 15 and 45 years of age. This may be due to the fact that women in the third trimester of pregnancy (the last three months) are at increased risk of developing Bell’s palsy. In addition, there appears to be a higher incidence of Bell’s palsy in winter.
What causes Bell’s palsy?
Bell’s palsy is an idiopathic condition, meaning that no conclusive cause has been established. It has not yet been possible to find out why the facial nerve becomes compressed; however, links have been made with viruses (including herpes, influenza and respiratory tract infections), as well as a depleted immune system and stress.
Although no certain cause has been established, people newly diagnosed with Bell’s palsy should understand that they are unwell. It is important to get plenty of rest even if they have no other symptoms and to maintain a healthy diet. If you are at work or school, it may be necessary to take some time to recover.
What are the symptoms of Bell’s palsy?
Bell’s palsy often comes on suddenly, without warning, over a number of hours, peaking at 72 hours. In eight out of ten cases, recovery will take place over a period of weeks or months. Below, you will find a list of the main symptoms of Bell’s palsy:
- Partial or complete paralysis of (usually) one half of the face (including the inability to close the affected eye), sometimes accompanied by a ‘drooping’ of the affected side of the face, depending on the severity of the nerve damage.
- In approximately one per cent of cases, both sides of the face are affected.
- Sharp pain in the inner ear during the onset of paralysis.
- Impaired or altered sense of taste.
- Sensitivity to loud noise.
- A drying of the eye on the affected side, where the eye cannot be closed properly. Sometimes the inability to close the eye properly can result in the eye watering, as it over-compensates for being too dry. It’s important to use drops/ointments to keep the eye lubricated.
- Difficulty with eating, due to loss of control of the lips and cheek on one side; food may get trapped in some areas as a result, and there may be involuntary drooling.
- Difficulty with speaking clearly, particularly with pronouncing particular sounds and letters, such as ‘B’ and ‘P’.
- Streaming nostril on the affected side, due to loss of muscle control around the nose.
How is Bell’s palsy diagnosed?
The diagnosis of Bell’s palsy is a diagnosis made by exclusion (that is, by ruling out other possible causes).
A doctor will carry out a neurological examination. He/she will ask you to perform a range of facial movements, such as closing your eye, puckering your lips, raising your eyebrows and smiling. A diagnosis of Bell’s palsy is likely if you have rapidly lost the ability to move the affected side of your face at all, or your facial movement is severely impaired and you have no other symptoms or signs.
To eliminate any other potential causes, your doctor may also request that you undergo:
- Blood tests to rule out other potential causes, such as Lyme disease and Ramsay Hunt syndrome.
- Imaging, such as magnetic resonance imaging (MRI) and computerised tomography (CT scan), to rule out other potential causes such as tumours.
- Tests with an Ear, Nose and Throat (ENT) specialist.
- A nerve test called electromyography (EMG) may be requested sometime after the onset of facial paralysis to identify if the facial nerve has been damaged, and if so, how much damage has taken place. It is not a diagnostic test but gives useful information about how the facial nerve is working. Find out more about medical tests.
What is the initial treatment for Bell’s palsy?
The best recovery occurs where the duration and severity of nerve compression (inflammation) is minimised. The main treatment to help reduce inflammation and therefore relieve pressure on the facial nerve is oral steroids. If Ramsay Hunt syndrome is suspected antiviral drugs should be prescribed in addition.
Steroids and antiviral medication need to be given within 72 hours of the symptoms appearing in order to have any beneficial effects.
- Prednisolone is the steroid usually prescribed for the treatment of Bell’s palsy and has been shown to reduce the severity of an attack. Please note that after 72 hours there is no evidence that steroids are effective in improving recovery.
- Aciclovir is the antiviral drug which is often prescribed for the initial treatment of facial nerve palsy where it is suspected that Ramsay Hunt syndrome (a viral infection) is responsible, for example, due to the presence of a rash or blisters in or around the ear, scalp or hair line. The blisters may also appear inside the mouth. Recent studies show that antivirals do not improve the outcome for patients with Bell’s palsy.
Please also note that in spite of prompt treatment with steroids, some patients will not recover fully but it is not fully understood why this is the case. Find out more about steroids and antivirals.
Eye care is extremely important in the initial stages of Bell’s palsy. It is very likely that you will not be able to close the eye or blink fully and therefore you will need to protect the affected eye from becoming damaged. Your doctor or pharmacist will be able to prescribe/supply you with artificial tears, to ensure that your cornea is kept moist and protected. If the paralysis is complete, you should also tape your eye closed at night.
Please note that although tempting, it is important not to try to make your face move by doing forceful facial exercises. This is because there is evidence to suggest that exercising of this nature can encourage the development of synkinesis (miswiring of nerves; see ‘Complications’ section below). It may also encourage the unaffected side to become even stronger because of forcing or exaggerating facial movements. See more information about facial nerve recovery.
The video below has tips how to manage your facial palsy while your face is floppy. Please note this is a series of 7 short videos in one.
Treatment for prolonged/permanent Bell’s palsy
If full recovery is not obtained within three months, it may be that the nerve damage was more extensive and additional treatment is required. Patients who have not fully recovered should be referred to a specialist for investigations to exclude other possible causes of facial weakness. Treatments include:
- Referral to a physiotherapist or speech and language therapist for facial rehabilitation therapy: if your symptoms persist beyond three months, go to your GP and ask that they refer you to a therapist who has specialist knowledge about the management of Bell’s palsy.
- Referral to a specialist doctor who is experienced in the management of facial palsy and the use of botulinum toxin injections. The aim is to reduce overactivity in muscles which are tight and or twitchy, to relax involuntary or unwanted movement (synkinesis), and to restore a more balanced facial expression.
- In a small number of cases, when after a prolonged period of time (a minimum of two years) the person is still experiencing severe symptoms, some surgical procedures may be required. It is unlikely that surgical procedures will be offered unless the person has undergone a period of facial therapy to try and improve muscle tone and facial expression and any synkinesis (involuntary movements).
What is the prognosis of Bell’s palsy?
The length of time it takes for the pressure on the nerve to be released and for it to recover is dependent on the initial damage.
- A large review showed that just over 70 per cent of people with Bell’s palsy make a full recovery. Improvement can occur as early as two to three weeks from onset; however, a full recovery can take anywhere from three to six months and beyond.
- In the remaining 20-30 per cent of cases, the nerve damage is more severe and these individuals are left with ongoing symptoms, i.e. the muscles may not remain paralysed, difficulties may be due to synkinesis. Severe nerve damage is more likely to occur if the patient
- Is over 60;
- Had severe pain at onset;
- Had complete rather than partial paralysis at onset;
- Had a preexisting health condition such as diabetes or high blood pressure;
- Was pregnant at the time of onset;
- If recovery had not begun after six weeks.
- Seven per cent of patients have recurrent Bell’s palsy, with the average interval between attacks being ten years.
Newer and more advanced treatments are able to assist people with severe nerve damage with managing their condition, in terms of expressiveness, facial function and appearance.
What are the possible complications of Bell’s palsy?
Due to the complexity of our facial muscles and their function, a number of problems can arise following the prolonged experience of having Bell’s palsy:
- Contracture: Shortening of the facial muscles over time may make the affected side of the face appear to be slightly ‘lifted’ in comparison to the unaffected side, and the affected eye may appear smaller than the unaffected eye. The fold between the outer edge of the nostril and the corner of the mouth may seem deeper due to the increased contraction of cheek muscles on that side.
- Crocodile tears: This means that the affected eye waters involuntarily, particularly whilst eating. This is due to faulty ‘re-wiring’ of the nerves during the recovery phase.
- Lagophthalmos (pronounced lag-op-thal-mus): This is an inability to close the affected eye, which if prolonged may result in eye dryness and/or corneal ulceration. (This complication can be assisted/prevented by the use of artificial tears and taping the eye down at night.) In rare cases, the vision may be permanently damaged if care is not taken.
- Synkinesis (pronounced syn-k-eye-nee-sis): This means that when intentionally trying to move one part of the face, another part automatically moves. For example, on smiling the eye on the affected side automatically closes. Similarly, on raising the eyebrows or closing the eyes, involuntary contraction of the cheek or neck muscles occurs. Find out more about synkinesis.
- People with persistent symptoms of Bell’s palsy may experience psychological problems including stress, anxiety, depression and low self-esteem. Please see our support section for further advice.
Frequently asked question(s)
Is it normal for the Bell’s palsy side of the face to suddenly feel very bruised one week in?
Yes it can feel tender/bruised both early on and later on too if synkinesis sets in.
Are there any exercises I can do to make my face recover quicker?
When your face is not working as it should, it is very tempting to try and force the muscles back to work by doing facial exercises. Never attempt to carry out exercises without professional help as you may do more harm than good. Most people want to do something but trying too hard may lead to problems later on in your recovery. There is evidence to suggest that exercising the facial muscles too forcefully can lead to a miswiring of the nerves as they recover, leading to longer term complications known as synkinesis. Your facial nerve is no different to any other part of the body and will take time to heal. Gentle facial massage is preferable to forceful exercises, using the pads of your fingers gently massage the brow, temples, cheek, chin and neck. If you are concerned about how your recovery is going after two to three months, ask your GP to refer you to a physiotherapist or speech and language therapist for assessment and treatment. They should have specialist experience in the management and treatment of facial palsy. Our self-help videos demonstrate techniques to help with your facial nerve recovery. Read more information about facial nerve recovery here: Facial Nerve Recovery.
I think I have Bell’s palsy, what should I do?
If you suspect that you have Bell’s palsy, then you should visit your GP or attend A & E as soon as possible. It is important to seek medical advice within 72 hours of onset, as research indicates that this is the optimum period of time in which Bell’s palsy will successfully respond to treatment. Find out about the way it is treated here.
Your health professional might also consider:
Stroke – Bell’s palsy is the most common cause of sudden facial weakness but a stroke should always be ruled out by a health professional.
Ramsay Hunt syndrome – If you have severe pain around the ear usually followed by a rash of blisters in or around the ear, scalp or hair line, or in the mouth or throat.
Lyme disease – If you have a history of tick exposure/camping holiday, or a rash (not always present). If you have flu like symptoms, joint pain or tiredness.
Should I take time off work with Bell’s palsy?
When first diagnosed with Bell’s palsy you should understand that you are unwell. It is important to get plenty of rest even if you have no other symptoms. You should also maintain a healthy diet. If you are at work or school, it may be necessary to take some time to recover.
Famous faces who have experienced Bell’s palsy at some point in their lives include Pierce Brosnan, George Clooney, Glenda McKay, Graeme Garden and BBC journalist John Sudworth.
The important thing to remember is not to panic. Discovering that you have Bell’s palsy can be a frightening time, and we hope that our website can provide you with lots of useful information, tips and advice as well as reassurance in discovering you are not alone.
Your GP will be able to discuss the physical impact of your condition with you and refer you on to facial palsy specialists such as physiotherapists, speech and language therapists and facial palsy clinics. Your GP will also be able to refer you for various talking therapies if you are struggling to come to terms with the psychological, emotional and psychosocial impact of having Bell’s palsy.
Remember that Bell’s palsy is relatively rare and your GP may not know that there is help in the form of facial rehabilitation. If your GP is reluctant to refer you to a therapist who is experienced in the management of facial palsy, then direct him to this website. You may need to insist if he/she is dubious about the help that is available.
- Referral to a specialist
- Steroids, antivirals & antibiotics
- Synkinesis advice
- Facial rehabilitation
- Dry eye advice
- Eye taping information
- Botulinum toxin (Botox)
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Last reviewed: 20-02-2021 || Next review due: 11-04-2022