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Health condition · Clinically reviewed

Facial palsy, from Bell\'s palsy to specialist reanimation.

Rapid, unilateral facial weakness is frightening - and time-sensitive. Prednisolone within 72 hours, meticulous eye care, and specialist rehabilitation change outcomes.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, ENT UK, ABN and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including high-dose prednisolone within 72 hours, House-Brackmann grading and specialist facial palsy rehabilitation.

Key facts

Facial palsy at a glance.

The essentials, in plain English - what it is, how it is graded, and how it is treated in the UK today.

  • What it is

    Weakness of the muscles supplied by the facial (VII) nerve, most often on one side. Bell's palsy accounts for around 70 per cent of acute cases.

  • The critical question

    Is the forehead affected? Forehead weakness suggests a lower motor neurone cause. A spared forehead with limb weakness points to stroke and needs urgent assessment.

  • Presentation

    Rapid onset of drooping mouth, incomplete eye closure, drooling, altered taste, hyperacusis and, at times, pain behind the ear.

  • First priority

    Protect the eye. Preservative-free lubricants by day, ointment and taping at night to prevent corneal exposure and ulceration.

  • Best-evidenced therapy

    High-dose oral prednisolone within 72 hours of onset for Bell's palsy, with combined antivirals for Ramsay Hunt syndrome.

  • When recovery stalls

    Specialist facial palsy rehabilitation, botulinum toxin for synkinesis, and facial reanimation surgery in commissioned UK centres.

Why this guide matters

A time-sensitive diagnosis, with a clear pathway.

Facial palsy has a short window for the most effective treatment. The three points below shape everything else on this page.

  • Rule out stroke first

    A spared forehead with arm, leg or speech signs is stroke until proven otherwise. Call 999 - do not wait for a GP appointment.

  • Prednisolone within 72 hours

    For Bell's palsy, high-dose oral prednisolone started within three days of onset gives the best chance of full recovery.

  • The eye is the emergency

    If the eye will not close fully, meticulous lubrication and overnight closure protect the cornea while nerve function returns.

How the diagnosis is made

From first symptom to a clear plan.

The steps a UK GP, ENT surgeon or neurologist will follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Onset and speed

    Sudden (hours to days) suggests Bell's or Ramsay Hunt. Gradual weakness over weeks or months raises concern for a tumour.

  2. 02

    Assessing

    Upper or lower motor neurone

    Forehead spared with limb signs equals stroke pathway. Forehead involved equals a lower motor neurone facial palsy.

  3. 03

    Assessing

    House-Brackmann grading

    A universal I to VI score for facial weakness, used at baseline and to track recovery across the whole team.

  4. 04

    Confirming

    Ear, mouth and skin exam

    Look for vesicles in the ear canal, palate or tongue (Ramsay Hunt), a parotid mass, cholesteatoma or an erythema migrans rash.

  5. 05

    Confirming

    Selective investigations

    MRI of the brain, internal auditory meatus and parotid for atypical, gradual, recurrent or bilateral cases. Lyme, HIV and syphilis serology when indicated.

  6. 06

    Preparing

    Audiometry and electrophysiology

    Pure tone audiometry when hearing is affected. Electroneuronography and electromyography help prognosticate severe or slow-recovering palsies.

  7. 07

    Preparing

    Specialist referral

    Commissioned UK facial palsy services (including Queen Square, Oxford and Manchester) coordinate ENT, neurology, oculoplastic and facial plastic input.

Typical timeline: acute assessment within hours, imaging within days when indicated.

Symptoms

What facial palsy actually looks like.

The classic pattern of unilateral facial weakness, incomplete eye closure and altered taste - and the features that mean urgent review.

  • Drooping mouth and cheek

    A one-sided sag of the mouth with loss of the nasolabial fold - often the first change others notice.

  • Incomplete eye closure

    Lagophthalmos - the eye will not fully close. The main risk is corneal exposure, drying and ulceration.

  • Bell's phenomenon

    On attempted closure the eye rolls upward. Reassuring for corneal protection but not a substitute for lubrication.

  • Forehead weakness (LMN)

    Loss of forehead wrinkling on the affected side. A spared forehead with limb weakness suggests stroke.

  • Altered taste and salivation

    Reduced taste on the front two-thirds of the tongue and dry mouth from chorda tympani involvement.

  • Hyperacusis and ear pain

    Sound feels uncomfortably loud (stapedius weakness). Posterior auricular pain is common in Bell's palsy.

  • Vesicles in the ear or mouth

    Herpes zoster oticus (Ramsay Hunt) - vesicles in the ear canal, palate or tongue with facial weakness.

  • Red flag - bilateral palsy

    Bilateral facial weakness has a specific differential - Lyme, Guillain-Barre, sarcoid, HIV and Mobius syndrome.

Treatment

How facial palsy is treated in the UK.

Prednisolone within 72 hours, antivirals for Ramsay Hunt, meticulous eye care and specialist rehabilitation - with reanimation surgery in commissioned centres when recovery is incomplete.

  • High-dose prednisolone

    For Bell's palsy - 50 to 60 mg oral prednisolone daily for 5 to 10 days, started within 72 hours of onset. The best-evidenced acute treatment.

  • Antivirals for Ramsay Hunt

    Aciclovir or valaciclovir combined with prednisolone within 72 hours - reduces the risk of long-term weakness and deafness.

  • Antibiotics for Lyme

    Doxycycline for Lyme-related facial palsy, particularly bilateral cases with a suggestive history or rash.

  • Meticulous eye care

    Preservative-free drops by day, lubricating ointment at night, tape or moisture chamber overnight - continue until closure returns.

  • Facial palsy rehabilitation

    Specialist facial physiotherapy, mirror work, biofeedback and facial retraining to build controlled, symmetrical movement.

  • Botulinum toxin for synkinesis

    Targeted injections quieten unwanted co-movements such as eye closure with smiling, and rebalance a tight, over-active side.

  • Oculoplastic eye surgery

    Upper lid gold or platinum weight, lower lid support and tarsorrhaphy protect the cornea when closure will not fully return.

  • Facial reanimation surgery

    Static slings and dynamic options - temporalis transfer, cross-facial nerve graft, free gracilis - in commissioned UK centres.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, ENT surgeon or neurologist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE CKS. Bell's palsy - management summary.

  • ENT UK. Facial nerve palsy - clinical guidance.

  • Association of British Neurologists. Bell's palsy and facial nerve disorders.

  • Cochrane Reviews. Corticosteroids and antivirals for Bell's palsy and Ramsay Hunt syndrome.

  • Facial Palsy UK. Patient information and peer support.

Red flags

When facial palsy needs urgent attention.

Most acute unilateral palsies are Bell\'s palsy and manageable in primary care. These are the patterns that are not - and where urgent input is needed.

  • Forehead spared with limb weakness

    A stroke pattern. Call 999 - urgent stroke pathway assessment and imaging.

  • Gradual weakness over weeks

    Progressive facial palsy over more than three weeks suggests a tumour and needs urgent MRI of the brain, internal auditory meatus and parotid.

  • Bilateral facial palsy

    A specific differential - Lyme, Guillain-Barre, sarcoid, HIV. Same-day medical review with lumbar puncture and targeted bloods.

  • Vesicles with facial palsy

    Ramsay Hunt syndrome - vesicles in the ear canal, palate or tongue. Start prednisolone and antivirals within 72 hours.

  • Corneal pain, redness or blurring

    Exposure keratitis. Same-day ophthalmology - untreated it can scar or perforate the cornea.

  • Recurrent facial palsy

    A second episode on either side warrants MRI, sarcoid and infection screening, and consideration of Melkersson-Rosenthal syndrome.

  • Parotid mass with palsy

    A facial nerve palsy with a lump in the parotid gland is a malignant parotid tumour until proven otherwise. Urgent head and neck referral.

  • Ear discharge with palsy

    Facial palsy with chronic ear discharge suggests cholesteatoma or acute otitis media - urgent ENT.

  • No improvement at three weeks

    Bell's palsy that has not started to recover by three weeks should be re-imaged and reviewed by a facial nerve specialist.

Living with it

A recoverable condition, with a long tail.

Four things that make the biggest difference day to day - protect the eye, move gently and specifically, expect a slow recovery, and lean on specialist support.

A quiet reminder

Small, specific movement beats big, forced effort.

Over-training a recovering face can embed synkinesis. Guided, mirror-based rehabilitation is worth the wait.

  1. 01 Eye

    Protect the eye every day

    Preservative-free drops hourly if needed, ointment and taping at night. Continue until you can fully close the eye without effort.

  2. 02 Rehab

    Slow, specific movement

    Small, mirror-guided movements beat big, forced grins. Overworking a weak face embeds synkinesis rather than strength.

  3. 03 Recovery

    Recovery takes months, not weeks

    Most Bell's palsies improve substantially by three months, but full recovery can take a year - and some are permanent.

  4. 04 Support

    You are not alone

    Facial Palsy UK offers peer support, expert clinics and information. Psychological input matters as much as physical rehabilitation.

Frequently asked

Everything we get asked about facial palsy.

Quick answers on stroke versus Bell\'s, steroids, eye care and long-term recovery.

  • What is facial palsy?

    Weakness or paralysis of the muscles of facial expression, usually caused by a problem with the seventh cranial (facial) nerve. It most often affects one side of the face and causes a drooping mouth, incomplete eye closure, drooling and altered taste. Bell's palsy - an idiopathic lower motor neurone facial palsy - is by far the most common cause.

  • How do I know it is not a stroke?

    The forehead is the key. In Bell's palsy and other lower motor neurone causes, the forehead is weak and you cannot raise the eyebrow on the affected side. In a stroke, the forehead is usually spared and there is often accompanying arm or leg weakness or speech disturbance. Any facial weakness with those extra features needs 999 and the stroke pathway.

  • Should I take steroids for Bell's palsy?

    Yes, in most cases. High-dose oral prednisolone (typically 50 to 60 mg daily for 5 to 10 days) started within 72 hours of onset gives the best chance of full recovery. Combined antivirals are added for Ramsay Hunt syndrome and are considered case by case in severe Bell's palsy.

  • How do I look after the eye?

    Preservative-free lubricant drops during the day (as often as hourly if the eye is exposed), lubricating ointment at night, and tape or a moisture chamber to keep the eye closed overnight. If the eye becomes painful, red or blurred, seek same-day ophthalmology review - corneal exposure can scar the surface of the eye if it is missed.

  • What if I do not fully recover?

    Around 20 to 30 per cent of Bell's palsies leave some long-term weakness or unwanted co-movement (synkinesis). Specialist facial palsy rehabilitation, botulinum toxin, and - when needed - eyelid or facial reanimation surgery in a commissioned UK centre can transform function and appearance.

  • Can facial palsy come back?

    Recurrence is uncommon but recognised, and warrants imaging (MRI brain, internal auditory meatus and parotid) plus screening for sarcoidosis, Lyme, HIV and Melkersson-Rosenthal syndrome. A second episode should never be labelled as Bell's palsy without a full work-up.

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